After a Mastectomy, Medicare May Also Cover Surgery on the Other Breast and Pay a Share of the Bill

Many women believe Medicare only pays to rebuild the breast removed for cancer and leaves surgery on the healthy breast out of the picture. That mistaken assumption can lead to bills worth thousands of dollars.

Consider a 68-year-old woman enrolled in Original Medicare who has had her left breast removed because of cancer. As she thinks about reconstruction, she expects Medicare to help with the side that was taken off. The right breast, which is still healthy, seems different to her. She assumes reshaping it so both sides match would count as cosmetic surgery and that she would have to pay for it herself. The situation is hypothetical, but the coverage issue is real.

That assumption is wrong. Medicare’s national coverage rule includes reconstruction on the healthy breast after a medically necessary mastectomy. If surgery is needed to make both sides match, it may be covered, leaving the patient responsible only for the usual cost-sharing rather than the full amount.

Medicare’s Rule Includes the Healthy Breast

This protection has been in place since January 1, 1997. The Centers for Medicare & Medicaid Services includes both breasts in national coverage determination 140.2. It applies after a mastectomy for any medical reason, not just cancer.

The rule refers to the other side as the “contralateral” breast. For someone who has had only one breast removed, that means the healthy breast may be reshaped as part of covered reconstruction so the two sides match.

What Determines Whether You Pay Everything or Only Your Share

When reconstruction is covered, the patient’s out-of-pocket cost depends on where the surgery takes place and whether she has supplemental insurance. Under Original Medicare, the costs break down this way:

• Outpatient surgery: After the annual Part B deductible, which is $283, the patient generally pays 20% of the Medicare-approved amount for doctors who accept that amount as full payment. The facility bills separately. A hospital outpatient department usually charges a copayment, while an ambulatory surgery center usually charges 20% of its approved amount.
• Inpatient surgery: Part A covers the hospital stay, subject to a $1,736 deductible per benefit period. The surgeon and other doctors bill Part B separately, so paying the hospital deductible does not eliminate those separate charges.

Reconstruction may be done at the same time as the mastectomy or later. CMS ties coverage to the mastectomy itself and does not set a deadline. Even if chemotherapy and radiation are completed first, the patient can still qualify for reconstruction of the healthy side if the medical records connect the procedure to the mastectomy.

Where Medicare Draws the Cosmetic Line

Medicare will not pay for changes done only for appearance. But matching the healthy breast to the reconstructed one can be part of medically necessary care. The same is true for other needed treatment, such as addressing a complication from reconstruction.

The medical record should make clear what each procedure is intended to do and how it relates to the mastectomy. The claim does not need to suggest that the patient still has active cancer if she does not. What it does need is an accurate diagnosis and documentation supporting the reconstruction.

People with Medicare Advantage face one additional issue. Those plans use their own networks and may require prior authorization before staged surgery. If reconstruction will continue into the coming year, the patient should make sure the plastic surgeon remains in the plan’s network before renewing coverage.

Many women know about the Women’s Health and Cancer Rights Act, but that law applies to group health plans and individual insurance. For Medicare beneficiaries, the governing rule is CMS determination 140.2.

Three Things to Do Before Scheduling Surgery

1. Ask the surgeon’s billing office how each stage will be coded and billed. Make sure the procedure on the healthy breast is billed as reconstruction and linked to the mastectomy diagnosis.
2. If you have Medicare Advantage, ask which procedures need prior authorization and have the surgeon submit the planned reconstruction. Get any approvals in writing, and confirm which stages and dates they cover. Do not assume approval for one operation covers every later visit or procedure.
3. If a claim is denied as cosmetic, appeal and cite NCD 140.2 by number. Include the sentence referring to the “contralateral unaffected breast” and attach operative notes showing the connection to the mastectomy.

The healthy breast does not have to be excluded from covered reconstruction. Before assuming the entire bill is hers to pay, the patient should ask the surgeon to document the medical need and request an estimate that includes both the physician and facility charges. Medicare can cover reconstruction on both sides, and the final bill depends on the care received and the coverage in place.