There are over three million women in the United States with a history of breast cancer, and 12 percent of all women in the country are at risk of developing breast cancer at some time in their lives. The risk is lower for men, but 1 out of every 883 men in the U.S. is diagnosed with breast cancer.
Fortunately, the number of deaths due to breast cancer have been steadily declining since 1989. This is due to a heightened awareness, early detection, and advances in treatment. Although breast cancer is the primary reason for having mastectomies, they are also an option for people who have severe, chronic breast pain, fibrocystic breast disease, or a family history of breast cancer.
If you are faced with the possibility of a mastectomy you should know the facts about your Medicare coverage and what to expect from surgery.
What is a Mastectomy?
A mastectomy is either the partial or complete removal of one or both breasts, done surgically. There are different types of mastectomy that are performed for different conditions. The most common types are:
• Total, or simple mastectomy which involves removal of the entire breast
without removing the muscles underneath.
• Double, or bilateral mastectomy includes removal of both breasts.
• Radical mastectomy includes removal of breast, lymph nodes from under
arm, and chest wall muscles.
• Modified radical mastectomy is the same as radical but the chest wall
muscles are not removed.
The type of mastectomy a person has depends on the patient’s age and health, the stage of menopause, the tumor size, stage, grade, and if it is a hormone-receptive tumor, and if the lymph nodes are involved.
Depending on the type of mastectomy and whether you have reconstruction surgery at the same time, you will be in the hospital for at least three days. Full recovery at home takes a few weeks. Your physician will give you a recovery plan that includes all the details.
Thanks to the Women’s Health and Cancer Rights Act of 1998, your Medicare coverage includes reconstructive surgery and prosthesis. There are several options that depend on the type of mastectomy you’ve had, but the 2 most common are breast implants and flap reconstruction.
If you decide to forgo reconstruction surgery and choose external, non-surgical options, your Medicare Part B benefits pay for 80 percent of the final cost of external breast prosthetics or mastectomy bras no matter when you have your surgery. You are also responsible for your yearly deductible of $185.00.
Medicare Benefits for a Mastectomy
Through Original Medicare Part A (Hospital Insurance) you will have inpatient hospital care coverage. This coverage includes mastectomy surgery as well as breast implant surgery that takes place during the primary operation. In order to be eligible for inpatient care you must meet the following requirements:
• You must have an official order from your doctor saying you need inpatient
hospital care to treat illness or injury.
• Your hospital must accept Medicare assignment.
In certain circumstances, there must be approval from the Utilization Review Committee of the attending hospital.
Under Original Medicare Part A, you are responsible for the $1,364.00 deductible for each benefit period involved. A benefit period begins on the day of admission to the hospital and extends to 60 consecutive days after the last day of inpatient hospital care. From day 1 of your inpatient care up to day 60, there is $0 coinsurance cost for each benefit period.
Your Part A benefits also pay for surgically implanted breast prosthesis after a mastectomy if the surgery takes place in an inpatient setting.
For prophylactic mastectomy due to family history or having an inherited mutation like BRCA1 or BRCA2, insurance coverage varies from state to state. Some states require coverage by law, so you should contact Medicare directly to find out about your state’s guidelines and requirements.
If you are facing mastectomy surgery, it is reassuring to know that you have Medicare coverage. Your physician and health insurance provider will sit down with you to discuss all your options for surgery, reconstruction, and hospitalization so you are fully aware of what to expect before and after your operation.