Mastectomy Requirements

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Breast Prostheses/Bras

  • Detailed Written Order
  • Patient's Name
  • Detailed Description of the Items to Be Ordered
  • Frequency of Use
  • Length of Time Patient Will Require the Item(s)
  • Physician's Printed Name
  • Physician's NPI
  • Physician's Signature
  • Physician's Date of Signature

Breast prostheses are covered after a radical mastectomy. Medicare will cover:

  • One silicone prosthesis every two years or a mastectomy form every six months.
  • As an alternative, Medicare can cover nipple prosthesis every three months.
  • Mastectomy bras are covered as needed.

There is no coverage for replacement prostheses due to wear and tear before the specified time frames. However, Medicare will cover replacement of these items due to:

  • Loss
  • Irreparable damage, or
  • Change in medical condition (e.g. significant weight gain/loss)

You are allowed only one prosthesis per affected side, others will be denied as not medically necessary even if attempting asymmetry (an Advance Beneficiary Notice should be provided in this circumstance).

Mastectomy sleeves which are used to control swelling are not covered in the home setting because they do not meet Medicare’s definition of prosthesis; however, it is possible that they may be covered under the hospital per diem if you request one during your hospital stay.

A mastectomy bra is covered if the pocket of the bra is used to hold a covered prosthesis or mastectomy form.

How do I qualify for a prosthetic bra? To qualify, you must receive Medicare benefits and have a doctor's prescription for breast prostheses and a prosthesis bra.

Oct 28, 2014 - It is federally mandated that insurance covers BOTH reconstruction and prosthetics. In other words, insurance cannot legally deny coverage for prosthetics, mastectomy bras and accessories which may or may not be needed after reconstructive surgery. This is outlined in the Women's Health and Cancer Care Act of 1998.

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