Original Medicare Coverage of Prophylactic Mastectomy

SHIPMEDICARE

Hi Everyone!,

Will Original Medicare (Medicare that isn't provided by a Medicare Advantage plan) cover a prophylactic mastectomy?

I am actually not a patient myself, but an advocate for an individual who is considering, due to her many high risk factors, having a prophylactic bilateral mastectomy. I am a certified Medicare counselor, employed by my state's SHIP (state health information) program. We provide high level, unbiased Medicare counseling and educational services for free to medicare beneficiaries, their caregivers and professionals. We are funded by a grant from the federal government to provide these services to Medicare beneficiaries within our state, (which is Alaska) but I am NOT a federal employee, nor am I a representative of CMS. I have been providing Medicare Counseling services 5 days a week, 8 hours a day for the last three years. I have a lot of experience providing detailed coverage information related to Medicare, and usually, know exactly where to look to find the information I need... in this case, I can find NOTHING. No information whatsoever.

I was contacted by a woman in her mid 50s who is considering having a preventative mastectomy. She is enrolled in both Medicare and Medicaid. She has many risk factors for breast cancer, including strong family history of breast cancer, previous diagnosis of colon cancer and has had a total hysterectomy to related to a diagnosis of uterine cancer. Her doctors are in agreement that the preventative mastectomy may be the best course of action for her and have referred her to a surgical specialist. My client wished to know whether Medicare would cover this surgery as she would not be able to afford it without the insurance coverage.

I cannot find a straight answer to this question. I have google searched the topic, read several policy manuals, looked at Medicare National Coverage Determinations Policy Book, searched the coverage determinations website of Noridian Healthcare (which is the state of Alaska's Medicare Coverage Determinations contractor) researched the topic on the medicare.gov website and looked in all of the Medicare related references books I have. Every place I've looked only every talks about coverage for reconstructive surgery after a mastectomy or breast prosthesis. The message boards and forums state some examples of Medicare covering such a procedure. Private insurance companies that provide Medicare Advantage plans have outlined some of the coverage guidelines, but when it comes to original medicare, these policies simply state that CMS makes their own coverage decisions.

I am very reluctant to tell my client, "I guess you'll just have to wait and see," so I've decided to reach out the community for help.

Has anyone on here, that has original Medicare, had Medicare cover their prophylactic mastectomy? If so, what information was needed in order to prove that the procedure was "medically necessary"? Was it a battle getting Medicare to cover the procedure? Did you have to appeal Medicare's original decision?

Any advice from those that have been through the trenches would be better than simply telling my client that I have no idea what will happen. I am open to ANY advice.

Thank you so much

kenyon

I am a SHIP Medicare Counselor in NH and to the best of my knowledge there is no current Federal ruling that will take into account insurance coverage for prophylactic mastectomy. To date, any coverage provided for this surgery has been legislated at the state level and, therefore, varies depending on the state of your residence or the state where your insurance is homed. As Original Medicare is a Federal insurance, prophylactic mastectomy would not be routinely covered by this insurance given lack of Federal legislation to this effect. I counseled one client a year ago who was insured under Original Medicare and seeking coverage for this procedure. What we discovered is that here, in NH, the best approach was to find a breast surgeon who was very supportive of this procedure to advocate the medical necessity through an appeals process. It was a very long struggle and in the end CMS did not approve coverage of the procedure. Hope you find this helpful.