Coverage for Breast Biopsy

Understanding Medicare Coverage for Breast Biopsy: A Comprehensive Guide

Breast biopsy is a crucial diagnostic procedure used to determine the presence of breast cancer or other breast conditions. If you’re a Medicare beneficiary facing a breast biopsy, understanding your coverage can alleviate financial concerns and ensure you receive the necessary care. Here, we delve into the specifics of Medicare coverage for breast biopsies, including eligibility, costs, and types of biopsies covered.

What is a Breast Biopsy?

A breast biopsy is a procedure to remove a small sample of breast tissue for laboratory testing. It’s typically done to investigate a suspicious area found during a mammogram, ultrasound, or MRI, or to evaluate other changes, such as a lump or thickening.

Types of Breast Biopsies

There are several types of breast biopsies, including:

  1. Fine Needle Aspiration (FNA): Involves using a thin needle to extract fluid or cells from a breast lump.
  2. Core Needle Biopsy: Uses a larger needle to remove tissue samples from the breast lump.
  3. Vacuum-Assisted Biopsy: Involves a probe that uses gentle suction to remove breast tissue samples.
  4. Surgical Biopsy: Involves removing a larger part of the breast lump for examination.

Medicare Coverage for Breast Biopsies

Medicare typically covers medically necessary breast biopsies, including the following aspects:

  1. Diagnostic Tests: Medicare Part B covers the cost of diagnostic tests, including mammograms and breast ultrasounds, which may lead to a biopsy if abnormalities are detected.
  2. Biopsy Procedure: Medicare covers the cost of the biopsy procedure itself, whether it’s a fine needle aspiration, core needle biopsy, vacuum-assisted biopsy, or surgical biopsy.
  3. Hospital Outpatient Services: If your biopsy is performed in a hospital outpatient setting, Medicare Part B covers the costs.
  4. Pathology Services: Medicare covers the costs of analyzing the biopsy sample in a laboratory to determine whether it’s cancerous or benign.

Medicare Part A vs. Part B Coverage

Medicare Part A covers inpatient hospital stays, but it does not typically cover outpatient procedures like breast biopsies. Medicare Part B, on the other hand, covers outpatient services, including breast biopsies performed in an outpatient setting.

Costs and Coverage Limitations

While Medicare covers a significant portion of the costs associated with breast biopsies, beneficiaries may still be responsible for certain out-of-pocket expenses, including:

  1. Deductibles: Medicare Part B has an annual deductible that must be met before coverage kicks in.
  2. Copayments/Coinsurance: Depending on the specifics of your Medicare plan, you may be responsible for a portion of the costs, typically a coinsurance amount or copayment.
  3. Medicare Advantage Plans: If you have a Medicare Advantage plan, coverage and costs for breast biopsies may vary, so it’s essential to check with your plan provider.

Coverage for Breast Biopsy


Understanding Medicare coverage for breast biopsies is essential for beneficiaries facing this procedure. By knowing what Medicare covers and what costs you may be responsible for, you can approach your biopsy with confidence, focusing on your health rather than financial concerns.

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  1. Does Medicare cover breast biopsy for all beneficiaries? Medicare covers breast biopsies for beneficiaries who meet certain criteria, such as having a doctor’s referral and meeting specific medical necessity requirements.
  2. Can I choose where to have my breast biopsy performed? Yes, Medicare allows you to choose where to have your biopsy performed, whether it’s in a hospital outpatient setting or a doctor’s office.
  3. Does Medicare cover the cost of follow-up care after a breast biopsy? Medicare typically covers follow-up care related to a breast biopsy, including additional tests or procedures deemed medically necessary.
  4. Are there any circumstances where Medicare may not cover a breast biopsy? Medicare may not cover a biopsy if it’s deemed unnecessary or if it’s performed for experimental or research purposes.
  5. How can I determine my out-of-pocket costs for a breast biopsy? You can contact Medicare or your Medicare Advantage plan provider to inquire about your specific coverage and out-of-pocket costs for a biopsy.