A mastectomy bra is a specialized post-surgical garment designed with interior pockets to securely hold an external breast prosthesis (breast form) in place. These garments are specifically shaped and constructed to provide comfort and support following a mastectomy, lumpectomy, or other breast surgery. Medicare generally covers the cost of mastectomy bras when they are considered medically necessary.
Coverage Under Medicare Part B
Coverage for mastectomy bras falls under Medicare Part B, the medical insurance component. Part B covers medically necessary outpatient services and supplies, including prosthetic devices. External breast prostheses and the specialized bras required to hold them are categorized as prosthetic devices under these guidelines. This coverage applies to individuals who have had a mastectomy (the surgical removal of breast tissue) or a lumpectomy that results in the need for a partial breast prosthesis. The bra is covered because its primary function is directly related to supporting the prosthetic device, helping to restore physical appearance and balance.
Annual Limits and Frequency Rules
Medicare sets specific rules regarding the frequency of replacement for mastectomy bras and external breast forms. The standard coverage limit allows for up to two new bras per calendar year for each person. This frequency is typically sufficient to account for normal wear and tear or changes in a person’s weight or size. If a patient experiences excessive wear, damage, or a greater need due to specific medical circumstances, a physician may justify a higher number of bras. The breast forms have a distinct replacement schedule based on the material. For example, silicone prostheses are typically covered for replacement every two years, while lighter fabric or foam forms may be covered every six months.
The Required Documentation and Supplier Process
To obtain coverage for a mastectomy bra, the beneficiary must first secure a prescription or a written order from a qualified physician, such as a medical doctor or doctor of osteopathic medicine. This document must state that the item is medically necessary following a covered surgical procedure. The prescription serves as the official documentation linking the need for the bra directly to the patient’s medical condition.
The item must be purchased from a supplier enrolled in Medicare, specifically a Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier. It is highly recommended to choose a supplier who agrees to accept “assignment,” meaning they accept the Medicare-approved amount as the total payment for the item. When a supplier accepts assignment, they are prohibited from billing the beneficiary for more than the deductible and coinsurance amounts. Beneficiaries should always confirm the supplier’s enrollment status and their agreement to accept assignment before finalizing the purchase. This simple verification helps prevent unexpected costs, as a non-participating supplier may charge the patient more than the Medicare-approved amount.
Financial Responsibility and Costs
Medicare Part B covers 80% of the cost of the mastectomy bra. The beneficiary is responsible for the remaining 20% coinsurance after meeting the annual Part B deductible. This deductible must be satisfied each year before Medicare begins to pay its share of the approved amount for any covered service or supply. Once the deductible is met, the patient’s financial responsibility for the bra is the 20% coinsurance.
Supplemental Coverage
This out-of-pocket expense can often be reduced or eliminated for beneficiaries who have supplemental insurance. A Medigap policy is designed to help cover the costs that Original Medicare does not pay, including the Part B coinsurance. Beneficiaries enrolled in a Medicare Advantage Plan (Part C) may have different cost-sharing rules, such as a fixed copayment or a different coinsurance structure for prosthetic devices. Individuals should consult their specific plan documents to understand their exact financial obligation.