What is the Medicare Reimbursement and Coverage for Post-Mastectomy Products?

by | Feb 15, 2019 | Shopping

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As part of your preparation for breast surgery, it is important to check your Medicare or other medical insurance regarding not only the surgical procedure but also the post-mastectomy products you may need and want.

Ask questions about coverage for specific products, the options you have for bras and other undergarments, and locate a specialty boutique or catalog store that can help you navigate the post-surgical lingerie-buying process. Numerous companies make comfortable, high-quality prostheses that look and feel natural. You can find Jodee breast forms, as well as Amoena, Nearly Me, and other reliable brands at many retailers.

What does Medicare cover?

If you have Medicare coverage, you are permitted to have as many mastectomy bras as you need; typically four to six annually. You may be eligible for additional bras if prescribed by your physician after weight loss/gain or surgery.

In addition, you may also obtain one of these three options: one foam breast form (or two for bilateral surgery) every six months, one silicone breast form (or two for bilateral surgery) every two years or one Perma-Form bra every six months. An allotment of three camis per month, as medically necessary, are included, as well.

For Medicare to pay for your post-mastectomy wear, the supplier must be enrolled in Medicare regardless of who files the claim.

How is Medicare reimbursement determined?

Medicare Part B medical insurance covers some peripheral breast forms and prostheses, as well as post-surgical bras after a mastectomy. Note that a licensed health care professional or physician must prescribe your post-mastectomy bras and prostheses or forms to receive a partial Medicare reimbursement.

Medicare Part B pays 80% of the Medicare-approved cost for external breast prostheses or forms, and the recipient is responsible for 20%. After Medicare pays their amount, a secondary insurance provider usually covers at least some of the remaining cost.

Claims to Medicare must be submitted by the business where the purchase was made. When Medicare receives payment and forms, they will reimburse you directly.

Reimbursement is determined by Medicare based on their evaluation of patient need. To determine the amount of your financial obligation for post-mastectomy supplies, discuss your case with your healthcare provider. What you owe depends on cost of the products, if you have other insurance coverage and the facility from which you get your forms, prostheses, camis, and bras.

Medicare publishes a helpful guide called “Reimbursement Fee Schedule for Bras and Prosthetics” to help you when determining allowable costs for Jodee breast forms for sale and post-mastectomy or Perma-Form bras and camis. It’s important to realize that amounts vary by state and are sometimes lower than retail prices.