Specialized garments, including external breast prostheses and the bras designed to hold them, are often necessary following a mastectomy for comfort and symmetry. Patients frequently ask about the financial burden of these items and coverage through federal health programs. This article outlines whether Medicare covers the cost of mastectomy bras and the requirements for obtaining this benefit.
Coverage Determination for Mastectomy Bras
Medicare covers mastectomy bras and external breast prostheses, provided the beneficiary meets specific medical criteria. This coverage is specifically provided under Medicare Part B, the portion of the program dedicated to medical insurance and outpatient services. Mastectomy bras and external breast prostheses are classified as prosthetic devices, which are generally covered benefits when deemed medically necessary. This benefit is available to individuals who have undergone a mastectomy, lumpectomy, or partial mastectomy. Medicare acknowledges that these specialized garments are needed to maintain posture, protect the surgical area, and properly secure external breast forms.
Specific Items and Quantity Limits
Medicare coverage for post-mastectomy supplies encompasses both external breast prostheses and the specialized bras required to hold them in place. External breast forms are typically covered for replacement once every two years. The specialized mastectomy bras, however, have different quantity limitations that reset annually.
Beneficiaries are generally covered for up to one or two new bras each calendar year, depending on the specific medical need determined by the prescribing physician. For patients with a bilateral procedure, coverage includes the necessary external forms and specialized support bras. The benefit may also include a weighted or non-weighted foam or fabric filler or custom-fabricated breast prostheses when a standard form cannot adequately fit the patient’s chest wall contours.
Out-of-Pocket Costs and Documentation
Since mastectomy supplies are covered under Medicare Part B, beneficiaries should anticipate certain out-of-pocket expenses. Patients must first meet the standard Part B annual deductible before Medicare begins contributing its portion of the costs. Once the deductible is satisfied, the beneficiary is generally responsible for a 20% coinsurance of the Medicare-approved amount for the prosthetic devices.
Obtaining coverage requires strict adherence to documentation requirements, primarily a physician’s written order or prescription. This document acts as proof of medical necessity, confirming the patient requires the post-mastectomy supplies following a qualifying surgical procedure. The prescription must clearly specify the exact items needed and must be dated prior to the items being dispensed. Patients must use a Medicare-enrolled supplier who accepts assignment, meaning they agree to charge no more than the Medicare-approved amount, limiting the patient’s financial responsibility.