Medicare Coverage for Double Mastectomy in 2025: Costs and What You Need to Know

When undergoing a double mastectomy, Medicare Part A typically covers inpatient hospital expenses, while Part B handles outpatient services related to the procedure.

Double mastectomy involves the removal of both breasts and is often performed to treat breast cancer or reduce cancer risk. Medicare generally covers medically necessary mastectomies following a cancer diagnosis, but elective procedures may have different coverage rules.

This guide explores Medicare’s coverage scope, including which parts pay for various services, out-of-pocket costs, and eligibility requirements for preventive surgeries and genetic testing.

Medicare Parts That Cover Double Mastectomy

Medicare provides extensive coverage for cancer-related treatments, including mastectomies, with some patient cost-sharing. Coverage varies by the type of service:

Outpatient Care and Physician Visits

Medicare Part B covers outpatient procedures, doctor consultations, and any outpatient surgery connected to the mastectomy.

Inpatient Surgery and Hospital Care

Medicare Part A handles inpatient hospital stays, including the mastectomy surgery and recovery.

Reconstructive Surgery

Post-mastectomy reconstruction involving surgically implanted prosthetics falls under Part A coverage. External prostheses and specialized post-surgical bras are covered through Part B.

Medicare Advantage (Part C) plans include all Part A and B benefits and may offer additional prescription and wellness benefits, depending on the plan.

Medications

Inpatient medications during hospital stays are covered by Part A. Certain oral chemotherapy drugs administered outpatient are covered by Part B. Prescription drugs related to surgery and recovery typically require Medicare Part D or a Medicare Advantage plan with drug coverage.

Preventive Mastectomy and Genetic Testing

Medicare’s coverage for prophylactic mastectomies is limited and often depends on state Medicaid programs. Cosmetic mastectomies are not covered.

Genetic testing for BRCA1 and BRCA2 mutations is covered if you have a personal breast cancer history and meet specific risk criteria, such as early diagnosis age, family history, or high-risk ethnic background.

Surgical Treatment Options

Breast cancer treatments include mastectomy (whole breast removal) and breast-conserving surgery (lumpectomy). Early-stage patients often opt for breast-conserving therapy combined with radiation, while mastectomy may be necessary based on tumor size, cancer stage, or genetic risk.

Medicare Coverage Rules and How to Ensure Eligibility

• Obtain a written doctor’s order confirming medical necessity for the mastectomy.
• Ensure the diagnosis codes align with Medicare’s International Classification of Diseases (ICD) system.
• Verify that your healthcare providers and facilities accept Medicare.
• For preventive mastectomies, submit documentation supporting high cancer risk and medical justification.

Medicare covers both implanted and external breast prostheses, including supportive garments like mastectomy bras. Visit Medicare’s official website to confirm coverage details for specific items.

Expected Out-of-Pocket Expenses for 2024

Medicare beneficiaries are responsible for deductibles, coinsurance, and copayments associated with mastectomy treatment.

Part A Costs

In 2024, Part A requires a $1,632 deductible per benefit period. After this, no additional costs are due for the first 60 days of hospitalization. Days 61–90 incur a $408 daily coinsurance, and days 91–150 involve a $816 daily coinsurance. Beyond this, patients pay full costs.

Part B Costs

Part B has a $240 annual deductible in 2024, followed by a 20% coinsurance on covered outpatient services, including doctor visits and external prostheses. There is no annual out-of-pocket maximum for Part B.

Part C Costs

Costs vary by Medicare Advantage plan but include premiums, deductibles, copayments, with a yearly out-of-pocket maximum.

Part D Costs

Prescription drug plans under Part D have varying premiums, deductibles (up to $545 in 2024), and copayments. Coverage gaps and catastrophic coverage phases affect final costs. Starting 2025, out-of-pocket prescription drug costs will cap at $2,000 annually.

Summary

Medicare generally covers double mastectomy costs related to cancer treatment, including surgery, medications, and prosthetics. Beneficiaries should prepare for some out-of-pocket expenses and ensure all medical documentation supports coverage eligibility.

Prophylactic mastectomy coverage is limited and requires thorough risk documentation. Cosmetic surgeries are not covered.

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