A biopsy is a medical procedure to remove sample cells or tissue for lab analysis — to determine the presence or degree of disease. Many types of biopsies exist. If you’re new to Medicare, it’s crucial to know what biopsies Medicare will cover.
In a nutshell: As long as it’s medically necessary, Medicare can pay for a biopsy to see whether you have cancer or another condition. Your costs (after Medicare pays its share) will depend on many variables, including location, supplemental insurance, and the kind of biopsy performed.
An Overview of Medicare Coverage for a Biopsy
Biopsies are often connected to cancer, but they can also help doctors identify and treat other health conditions. Your doc will surgically extract small tissue pieces during a biopsy and send it to a lab for testing. You could be under anesthesia.
The majority of biopsies are outpatient. You might get bills from facilities, doctors, and labs for the procedure. Medicare Part B — your medical insurance — covers biopsies administered in doctors’ offices or outpatient centers.
If your physician accepts Medicare assignment, you won’t pay a higher amount. But before Medicare chips in, you have to meet the yearly Part B deductible.
If you’re an inpatient at a hospital, Medicare Part A pays for biopsies. Part A has a deductible, too. But after you’ve hit that deductible, Part A pays ALL of the biopsy’s cost.
Medicare and Needle Biopsies
A needle biopsy involves a needle insertion into the body to get muscle, bone, or organ cells for testing. This type of biopsy may detect cancer or diagnose infections or inflammations. Two kinds of needle biopsies exist: fine-needle aspiration and core needle biopsy, and Medicare covers both.
Additionally, Medicare covers anesthesia and CT scans that your doctor may perform before or during the biopsy procedure.
Medicare and Prostate Biopsy
Medicare pays for a yearly test to screen for prostate cancer if you’re 50 or older. If your results reveal higher-than-normal levels of the antigen, your doc may require a biopsy to see whether cancer cells are present.
Your prostate biopsy will likely be done on an outpatient basis, which falls under Medicare Part B’s coverage.
Medicare and Breast Biopsy
Medicare pays for some breast cancer screenings. Women over 40 who have Medicare can get annual screening mammograms at no cost. Medicare also covers a manual breast exam every two years. If the exam indicates a lump or breast abnormality, your doctor may arrange a biopsy.
Original Medicare pays a percentage of the cost if your biopsy happens at a doctor’s office or outpatient center. With Medigap insurance, your biopsy may be covered in full.
Medicare and Oral Biopsies
While Medicare doesn’t cover dental care or cancer screenings at the dentist’s office, it DOES cover oral biopsies in the same manner as other biopsies.
An oral biopsy helps doctors diagnose mouth or throat cancers. Your dentist or doctor might refer you to a specialist if they think you have mouth cancer.
Do Medicare Advantage Plans Cover Biopsies?
If you have a Medicare Advantage (Part C) plan, it will cover biopsies, just like Original Medicare. But the private carriers who sell Advantage programs set deductibles and copays. So, your costs depend on the details of your plan.
Medicare Advantage plans have provider networks for doctors and hospitals — unlike Parts A and B. You’ll want to use doctors in the plan’s network to keep your costs low.
Medicare Supplements and Biopsies
All Medicare Supplement plans cover biopsies. However, with some policies, you’ll need to pay a flat fee (copay) or a percentage (coinsurance) of the bill. For instance, if you have Medigap Plan G, your plan will cover the Part B charges left over by Original Medicare — after you reach the deductible.
Remember that Medicare Supplements lower your out-of-pocket expenses for Medicare-covered services and procedures.
What Else You Should Know
- Medicare covers a bone marrow biopsy that’s medically necessary. Bone marrow biopsies can diagnose leukemia and other types of blood cancer.
- Medicare covers skin biopsies and treatment for skin cancer. Your doctor may call for a skin biopsy if you have irregularities on the surface of your skin that could suggest cancer.
- Medicare also covers endoscopic biopsies, whether you get one as part of a hospital stay or as an outpatient. This test can diagnose cancer in tissue inside your body — including colon, lung, and bladder cancer.
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