Exploring What Does Medicare Cover for Breast Cancer: A Comprehensive Guide

Breast cancer is among the most common illnesses in women worldwide, affecting one in eight women. Although a breast cancer diagnosis can be daunting and emotionally challenging, there are various treatment options and programs that can regularly alleviate the burden. But with all the different options out there, it can get overwhelming to determine which treatment program is covered under Medicare.

Medicare offers a wide range of coverage for breast cancer treatments. Patients can expect to have access to treatments such as radiation therapy, chemotherapy, and surgery, as well as rehabilitation services, mental health counseling, and physical therapy. Thanks to the Affordable Care Act (ACA), mammograms are covered under preventive services with no out-of-pocket expenses for policyholders.

With more than 60 million Americans who depend on Medicare for their health insurance needs, access to reliable health care coverage in the fight against breast cancer is now more important than ever, not only to the patients but also to the loved ones who support and care for them. It is imperative to understand the ins and outs of breast cancer coverage under Medicare to ensure that eligible patients can avail of the comprehensive coverage they deserve.

Types of breast cancer covered under Medicare

Having Medicare coverage can provide peace of mind to seniors who are diagnosed with breast cancer. This healthcare program offers various forms of breast cancer treatment, including surgeries, radiology, and chemotherapy. Below are the types of breast cancer that are typically covered under Medicare:

  • Invasive Ductal Carcinoma (IDC) – This is the most common type of breast cancer that accounts for roughly 80% of all reported breast cancer cases. IDC begins in the breast’s milk duct and eventually grows beyond the ducts, affecting nearby tissues.
  • Invasive Lobular Carcinoma (ILC) – This type of breast cancer begins in the breast’s milk-producing lobules and can spread throughout the body, including the brain, bones, and liver.
  • Paget’s Disease of the Nipple – This type of breast cancer starts in the milk ducts but eventually spreads to the nipple and areola. This is often accompanied by itchy, dry, or inflamed skin around the affected area.

It’s worth noting that the above-mentioned types of breast cancer are eligible for Medicare coverage only if the condition is in the early stages of development. The treatment and extent of coverage may differ based on the patient’s specific needs and other factors like the cancer stage, overall health, age, and the type of surgery.

Screening procedures covered by Medicare

One of the most important aspects of breast cancer is early detection. Medicare covers several screening procedures to help identify any breast cancer at an early stage when it might be more treatable and manageable.

The following are the screening procedures Medicare usually covers:

  • Mammograms: This is perhaps the most well-known diagnostic procedure for breast cancer, and Medicare Part B provides coverage for both screening and diagnostic mammograms. Women who are above 40 years old and at average risk for breast cancer are eligible for a mammogram every 12 months. For those who are at high risk, Medicare will cover one mammogram per year for women aged 35 years old and above.
  • Clinical Breast Exam (CBE): This physical exam is conducted by a healthcare provider. During the examination, the provider will check the breast for any lumps or abnormalities. Women are eligible for CBE once every year.
  • Breast Ultrasound: A breast ultrasound is used to evaluate a breast lump or abnormality that has been identified via a mammogram or CBE. Medicare usually covers this diagnostic procedure after a mammogram has been conducted.
  • Breast Magnetic Resonance Imaging (MRI): An MRI typically utilizes powerful magnets and radio waves to help create images of the breast tissue. MRI is useful for women who are at a higher risk for breast cancer due to a family history or carrying a mutation in the BRCA1 or the BRCA2 gene.


Medicare covers a suite of breast cancer screening procedures that enables eligible beneficiaries to detect any sign of breast cancer early. Early detection is critical to ensuring better treatment options and outcomes. Therefore, it is recommended for women to engage in screening procedures regularly. If you are interested in learning more about breast cancer screening procedures covered by Medicare, you should consult your healthcare provider or contact Medicare directly.

Diagnostic tests covered under Medicare for breast cancer

Medicare covers a range of diagnostic tests for breast cancer, which are typically covered under Part B medical insurance. These tests are designed to confirm a breast cancer diagnosis or rule it out, and include:

  • Mammograms: Medicare covers annual screening mammograms for women aged 40 and over, and diagnostic mammograms for those with symptoms or abnormalities.
  • Ultrasound: If a mammogram is inconclusive or further testing is needed, Medicare may cover an ultrasound to help diagnose breast abnormalities or masses.
  • Magnetic resonance imaging (MRI): Women at high risk of breast cancer may be covered for an MRI, which can produce detailed images of breast tissue.
  • Biopsy: A biopsy involves removing a sample of breast tissue for examination under a microscope. Medicare typically covers biopsy procedures for suspected breast cancer.

Breast cancer genetic testing

In some cases, Medicare may cover genetic testing for breast cancer if patients meet certain criteria. Genetic testing can help determine whether a patient has an inherited gene mutation that increases their risk of breast cancer. Medicare may cover genetic testing for patients with a personal or family history of breast or ovarian cancer, or those with a suspicious lump or growth. However, coverage may vary depending on the specific test and the patient’s medical history.

Breast cancer treatment

Medicare typically covers a range of breast cancer treatments, including surgery, radiation therapy, chemotherapy, and hormone therapy. The type of treatment recommended will depend on the stage and type of breast cancer, as well as other factors such as the patient’s overall health and preferences. Medicare may also cover reconstructive surgery after mastectomy, as well as follow-up care and screenings to monitor for recurrence.

Breast cancer screening frequency

Age range Screening frequency
40-49 Annual mammogram at physician discretion
50-74 Annual mammogram
75+ Consult with physician for personalized screening recommendations

While Medicare does cover annual mammograms for women aged 50 to 74, the screening frequency may vary depending on the patient’s age, risk factors, and overall health status. Women aged 40 to 49 should consult with their physician to determine whether annual mammograms are recommended based on their individual health history and risk factors. Patients aged 75 and older should also speak with their doctor to determine whether continued screening is appropriate.

Medicare coverage for surgery related to breast cancer treatment

When it comes to breast cancer treatment, surgery is often necessary to remove the cancerous tissue. Medicare does cover surgery related to breast cancer treatment, but it’s important to understand which types of surgeries are covered and under what circumstances. The following are some of the surgeries that Medicare will cover:

  • Lumpectomy – a surgical procedure that removes just the breast cancer and some surrounding tissue. Medicare will cover this type of surgery for women with early-stage breast cancer.
  • Mastectomy – a surgical procedure that removes all of the breast tissue. Medicare will cover this type of surgery for women with either early-stage or advanced breast cancer.
  • Reconstructive surgery – a surgical procedure that rebuilds the shape and look of the breast(s) after mastectomy. Medicare will cover this type of surgery if it’s deemed medically necessary.

It’s important to note that Medicare will cover surgery related to breast cancer treatment only if it’s deemed medically necessary. In addition, Medicare will cover the surgery at an approved facility and with an approved surgeon. If you choose to have the surgery done at a facility or by a surgeon that is not approved by Medicare, you may be responsible for the full cost of the procedure.

Below is a table that outlines the cost-sharing for Medicare-covered breast cancer surgeries:

Type of Surgery Cost-Sharing
Lumpectomy 20% of the Medicare-approved amount
Mastectomy 20% of the Medicare-approved amount
Reconstructive surgery 20% of the Medicare-approved amount

If you have additional coverage, such as a Medicare Supplement insurance policy, that may help cover the cost-sharing requirements of your Medicare-covered breast cancer surgery. It’s important to understand all of your coverage options so you can make informed decisions about your health care.

Medicare coverage for radiation therapy for breast cancer

Radiation therapy is a common treatment for breast cancer patients, and Medicare covers this treatment option. However, there are certain criteria that must be met in order for patients to be eligible for Medicare coverage.

  • The radiation therapy must be medically necessary and ordered by a doctor.
  • The treatment must be provided by a Medicare-approved facility.
  • Patients must have had breast-conserving surgery (lumpectomy) or a mastectomy.

Medicare coverage for radiation therapy for breast cancer may include:

  • External beam radiation therapy (EBRT)
  • Brachytherapy (internal radiation therapy)
  • Intraoperative radiation therapy (IORT)

Radiation therapy can have side effects, and Medicare may also cover any necessary medications or treatments to manage these side effects, such as anti-nausea medication or pain management medication. It’s important for breast cancer patients to discuss their treatment options and eligibility for Medicare coverage with their doctor.

Below is a table outlining some of the key information regarding Medicare coverage for radiation therapy for breast cancer:

Medicare Coverage for Radiation Therapy for Breast Cancer
Radiation therapy must be medically necessary and ordered by a doctor.
Treatment must be provided by a Medicare-approved facility.
Patients must have had breast-conserving surgery (lumpectomy) or a mastectomy.

With proper eligibility and medical necessity, Medicare can cover the costs associated with radiation therapy for breast cancer patients. Be sure to speak with your healthcare provider about your treatment options and insurance coverage to ensure the best possible care for you.

Chemotherapy coverage under Medicare for breast cancer treatment

Chemotherapy is a common treatment option for breast cancer patients, and Medicare covers many of the costs associated with this treatment. Below are some key points regarding chemotherapy coverage under Medicare for breast cancer treatment:

  • Medicare Part B covers most chemotherapy treatments that are given to breast cancer patients
  • Patient may be responsible for a small co-payment or co-insurance fee depending on the specific chemotherapy drug and location of treatment
  • Medigap supplemental insurance policies can also help cover some of these costs

It is important to note that patients should always confirm with their healthcare provider that the treatment plan they are receiving is covered by Medicare before beginning treatment.

Below is a table outlining some of the most common chemotherapy drugs used to treat breast cancer and their coverage under Medicare Part B:

Drug Name Covered under Medicare Part B?
Adriamycin (Doxorubicin) Yes
Cytoxan (Cyclophosphamide) Yes
Taxol (Paclitaxel) Yes
Herceptin (Trastuzumab) Yes
Perjeta (Pertuzumab) Yes
Abraxane (Nab-paclitaxel) Yes
Faslodex (Fulvestrant) Yes
Halaven (Eribulin) Yes
Navelbine (Vinorelbine) Yes
Taxotere (Docetaxel) Yes

Overall, Medicare provides comprehensive coverage for breast cancer treatment including chemotherapy. It is important for patients to work with their healthcare provider to ensure they receive the best treatment plan, and to confirm coverage under Medicare before beginning treatment.

Medicare coverage for follow-up care and survivorship programs for breast cancer patients

After completing breast cancer treatment, patients need to have regular check-ups and follow-up care. Medicare covers a variety of services and treatments for breast cancer survivors to ensure that they stay healthy and cancer-free. In addition to regular check-ups, Medicare also covers survivorship programs that provide emotional and social support to cancer survivors.

  • Yearly mammograms: Medicare covers a yearly mammogram for breast cancer patients at any age.
  • Diagnostic mammograms: Medicare covers diagnostic mammograms for patients who have symptoms or abnormal results from a screening mammogram.
  • Ultrasound: Medicare covers ultrasounds for patients with dense breast tissue or if a lump is found during a clinical breast exam.

In addition to the above mentioned, Medicare also covers the following services:

  • Annual wellness visit: This includes a review of your medical history, medication usage, and a physical exam. Your doctor may also order preventive screenings during this visit.
  • Psychological and psychiatric counseling: Medicare covers counseling services for patients with depression or anxiety related to their cancer diagnosis.
  • Dietary counseling: Medicare covers medical nutrition therapy for patients with breast cancer-related symptoms or side effects from treatment.

Other Medicare-covered services include lab tests, surgical procedures, and radiation therapy. Medicare Part B also covers durable medical equipment, such as prosthetics and orthotics used after breast cancer treatment.

Treatment/Service Medicare Coverage
Chemotherapy Medicare Part A and Part B
Radiation therapy Medicare Part A and Part B
Hospital stays Medicare Part A
Doctor visits Medicare Part B

It’s important for breast cancer patients and their caregivers to understand the coverage that is available to them under Medicare. With the right care and support, breast cancer survivors can live long and healthy lives.

FAQs: What does Medicare Cover for Breast Cancer?

Q: Does Medicare cover mammograms?
A: Yes, Medicare covers a screening mammogram once a year for women aged 40 and older.

Q: Does Medicare cover diagnostic mammograms?
A: Yes, Medicare covers diagnostic mammograms for women with symptoms or abnormalities found during a screening mammogram.

Q: Does Medicare cover breast cancer genetic testing?
A: Yes, Medicare covers genetic testing for those who meet certain criteria, such as a strong family history of breast cancer.

Q: Does Medicare cover breast cancer surgeries?
A: Yes, Medicare covers many types of breast cancer surgeries, including mastectomy, lumpectomy, and lymph node removal.

Q: Does Medicare cover breast cancer radiation therapy?
A: Yes, Medicare covers radiation therapy as a treatment for breast cancer.

Q: Does Medicare cover chemotherapy for breast cancer?
A: Yes, Medicare covers chemotherapy as a treatment for breast cancer.

Q: Does Medicare cover breast reconstruction after mastectomy?
A: Yes, Medicare covers breast reconstruction surgery and other related treatments after a mastectomy.

Thanks for Reading!

We hope this article has answered some of your questions about what Medicare covers for breast cancer. Remember to take advantage of all the services and treatments available to you. Stay informed and stay healthy! Make sure to come back for more updates on your healthcare options.