For women facing mastectomy—whether due to breast cancer, preventive surgery, or trauma—breast reconstruction can restore not only appearance but also self-confidence. A common question for those on Medicare is: Does Medicare cover breast reconstruction surgery? The answer is yes—but there are important details you should know about eligibility, costs, and coverage rules.
Medicare Coverage for Breast Reconstruction
Medicare considers breast reconstruction following a medically necessary mastectomy as reconstructive surgery, not cosmetic. This distinction is key because cosmetic procedures are not covered.
Under Medicare’s National Coverage Determination 140.2, reconstruction is covered for both the affected breast and the opposite breast when needed for symmetry. This includes implant-based reconstruction, flap procedures using your own tissue, and surgeries to correct complications from prior reconstruction.
Original Medicare (Parts A & B)
- Part A covers inpatient breast reconstruction performed in a hospital after mastectomy.
- Part B covers outpatient reconstruction, external breast prostheses, and post-surgical bras. Beneficiaries typically pay 20% coinsurance after meeting the Part B deductible.
Medicare Advantage (Part C)
Medicare Advantage plans must provide at least the same coverage as Original Medicare, but costs, networks, and prior authorization rules can vary. Always check your plan’s requirements before scheduling surgery.
Prostheses and Post-Surgical Garments
Recovery after mastectomy may involve the use of breast forms or specialized bras. Medicare covers external breast prostheses and post-surgical garments when prescribed by a doctor. These items are subject to the standard 20% Part B coinsurance.
Why Breast Reconstruction Is Not Considered Cosmetic
According to Healthline’s Medicare surgery coverage guide, Medicare differentiates reconstructive surgery—done to restore function or appearance after injury or illness—from purely cosmetic surgery, which is elective. Because breast reconstruction helps restore normal appearance and quality of life after mastectomy, it is covered under Medicare’s guidelines.
Legal Protections and Policy Context
The Women’s Health and Cancer Rights Act (WHCRA), passed in 1998, requires most group health plans to cover all stages of breast reconstruction, prostheses, and symmetry procedures after mastectomy.
Although Medicare is not bound by WHCRA, it has its own strong coverage rules. Facing Our Risk of Cancer Empowered (FORCE) provides an excellent breakdown of how WHCRA interacts with Medicare’s policies.
Timing and Surgical Options
Breast reconstruction can be done:
- Immediately during mastectomy surgery, which may reduce costs and recovery time.
- Delayed, weeks, months, or years later, depending on personal preference or additional treatments.
Surgical options include:
- Implant-based reconstruction – Using saline or silicone implants.
- Flap procedures – Using your own tissue (TRAM, DIEP, or latissimus dorsi flaps).
The American Society of Plastic Surgeons offers detailed explanations of each method, recovery expectations, and pros and cons.
What You’ll Pay Under Medicare
Even with coverage, you may have out-of-pocket costs:
- Original Medicare – 20% coinsurance under Part B and applicable Part A deductibles for hospital stays.
- Medicare Advantage – Copays, deductibles, and out-of-pocket maximums vary by plan.
- Medigap (supplemental insurance) – Can help cover coinsurance and deductibles.
For a deeper breakdown, Medicare.org’s breast reconstruction coverage article explains typical costs and how supplemental coverage may help.
How to Navigate Medicare Coverage
To get the most from your benefits:
- Document medical necessity – Your surgeon must provide detailed notes explaining why the procedure is necessary. Breastcancer.org’s reconstruction payment guide explains the importance of proper documentation.
- Confirm your surgeon is Medicare-approved – If you have Medicare Advantage, make sure they’re also in-network.
- Check prior authorization requirements – Medicare.gov’s cosmetic surgery coverage page outlines situations where pre-approval may be needed.
- Appeal if coverage is denied – You can file a Medicare appeal with supporting evidence.
Real Patient Experiences
Some patients opt for advanced options like the DIEP flap, which uses abdominal tissue for a more natural look. Recently, advocates fought to preserve DIEP flap coverage when Medicare coding changes threatened accessibility—highlighting the importance of staying informed about policy changes.
Key Takeaways
- Yes, Medicare covers breast reconstruction after a medically necessary mastectomy.
- Coverage applies to both breasts if needed for symmetry.
- Prostheses and post-surgical garments are also covered.
- Cosmetic-only procedures are not covered.
- Your out-of-pocket costs depend on your plan type and supplemental coverage.
Understanding the specifics of Medicare breast reconstruction coverage helps you plan your care, control costs, and advocate for the treatment you deserve.
