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Breast Prostheses

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

·                         One silicone prosthesis every two years or a mastectomy form every six 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)

·                 Patients are allowed only one prosthesis per affected side; others will be denied as not medically necessary even if attempting symmetry (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.