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 a 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:
- 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 ABN 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 a 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.