While out for a walk on a winter day, a neighbor stopped me. She was recently diagnosed with breast cancer and had concerns about what Medicare would cover. She isn’t alone with her worries. The American Cancer Society estimates that there will be almost 322,000 new cases of breast cancer in the United States in 2026.
The diagnosis and treatment of breast cancer are very involved and individualized. There is no way to provide all the information a newly diagnosed woman should know but this brief overview of some important points is a good place to start.
Diagnosis
There are four important diagnostic procedures.
Mammogram
There are two different coverage situations that apply to mammograms.
- Preventive screening: Medicare covers one baseline mammogram and then a screening once every 12 months for women 40 and over.
- Diagnostic: If a radiologist or physician identifies an abnormality that would require follow-up evaluation, a mammogram becomes diagnostic and subject to cost sharing and Medicare Advantage coverage rules. Medicare also covers a diagnostic mammogram when a woman has a new lump or mass, changes in the size or shape of skin of a breast or nipple, or pain. This could be a two-dimensional (conventional) or three-dimensional (for dense tissue) test.
Breast Ultrasound
This is a non-invasive imaging procedure used when the physician wants to get a detailed look inside the breast. This is usually after a mammogram has identified an abnormality or suspicious finding.
Breast MRI
A physician can order this procedure to further investigate any abnormalities identified by a mammogram or ultrasound. It is also indicated for women who are at high risk of breast cancer or have a gene mutation, such as BRCA1 and BRCA2.
(Read the CMS coverage determination to learn more about these three diagnostic tests.)
Breast Biopsy
Medicare covers a biopsy used to remove cells, tissue or fluids for examination. Medicare Part A covers biopsies that are performed for hospital inpatients. All other biopsies are covered under Part B.
Cost and Coverage Rules for Diagnostic Tests
Because it is a preventive service, there is no cost to the patient for a screening mammogram and prior authorization requirements do not apply. However, a follow-up test would put it into the diagnostic category, along with the ultrasound, MRI and biopsy.
These points apply to diagnostic tests.
- Original Medicare beneficiaries: If a test is done during a hospital stay, Original Medicare beneficiaries would be responsible for the Part A hospital deductible, $1,736 in 2026. For outpatient procedures, a beneficiary would pay the Part B deductible, $283 this year, and then a 20% coinsurance. A Medicare supplement plan can help with those out-of-pocket costs.
- Medicare Advantage: Each plan establishes its own cost sharing. In most cases, the plans charge copayments, either per-day for hospital stays or per-procedure for tests. Coverage rules apply so the tests are likely subject to prior authorization.
Medical Team
The team of physicians can include many “gists.”
- Surgical, medical, and radiation oncologists
- Radiologist
- Pathologist.
Other specialties include:
- Reconstructive surgeon
- Nurse practitioner
- Registered dietitian
- Social worker.
Once those with Original Medicare and a Medicare supplement plan pay the Part B deductible, there are no future costs. (Any supplement covers the 20% coinsurance.)
It’s very possible a Medicare Advantage patient will require a referral to see a specialist and prior authorization. As mentioned, the plan determines the costs, usually a per-visit copayment.
Treatment
The team develops a treatment plan for each patient. Here are some common treatment options.
Surgery
There are two common procedures.
- A lumpectomy, also called a partial mastectomy, removes tissue that includes the tumor and a thin layer of healthy tissue surrounding it.
- A mastectomy involves removing the entire breast.
Over half of mastectomies are now done on an outpatient basis.
Radiation Therapy
Radiation therapy is planned specifically for each patient’s body shape and internal anatomy so treatment sessions must be at the same facility. Treatment is most often given once a day, Monday through Friday, for one to six weeks.
Physical Therapy
After surgery, physical therapy can help reduce pain, improve strength and restore range of motion.
Drugs for Cancer Treatment
As with every aspect of breast cancer treatment, medications play an important role and are very specific for each situation. The drug regimen (type of medications, frequency) depends on the individual.
- Chemotherapy can be administered orally in pill form or intravenously.
- Targeted drug therapy uses specialized medications to attack the cancer cells while minimizing damage to healthy cells. This therapy can last anywhere from a year to five years or longer. The American Cancer Society has an overview of different drug therapies on its website.
- There are medications to treat the effects of cancer and the side effects of treatment.
Cost and Coverage of Cancer Drugs
As a general rule, Medicare covers drugs administered intravenously under Part B and taken orally under Part D. However, if a physician can give an anti-nausea drug by mouth or intravenously within 48 hours of chemotherapy, Part B would cover both the oral and IV drugs.
For intravenous medications:
- Original Medicare beneficiaries face the Part B deductible and the 20% coinsurance.
- Those who elected Medicare Advantage usually pay a 20% coinsurance in-network and up to 50% out-of-network, along with prior authorization requirements.
- If chemotherapy is administered in a hospital setting, the copayment cannot be more than the inpatient deductible amount.
Part D medications are subject to the deductible and whatever cost sharing the Medicare drug plan (standalone or part of an Advantage plan) applies. Some of these drugs can be costly, so the patient reaches the $2,100 cap in a few months.
(On the medicare.gov website, download “Medicare Coverage of Cancer Treatment.”)
Long-term Follow-up Care
The type, intensity and frequency of follow up depends on the individual situation and can continue as long as the services are still considered reasonable and necessary.
Generally, a mammogram is considered diagnostic for three to five years. If there’s no evidence of recurrence, the test transitions to screening. Oncologist visits tend to decrease in frequency as the patient moves from active cancer to annual surveillance. After a certain time, such as 10 years, follow-up care may transfer to the primary physician.
Other Issues
A few concerns merit attention.
Breast Self-exam
Until the American Cancer Society officially recommended screening mammography for the general population in 1976, visual inspection and touch were the screening tools. Then, in 2009, the U.S. Preventive Services Task Force recommended against teaching self-exam and, in 2015, the American Cancer Society followed suit. Now these organizations recommend breast self-awareness, knowing what is normal with one’s body.
Either way, breast self-exam and breast self-awareness are non-invasive, with no cost or prior authorization requirements, and may be valuable. A 2003 study found that 25% of women detected the cancer by self-examination
Lymphedema
Lymphedema is the swelling of subcutaneous tissues due to the accumulation of excessive lymph fluid, a complication of surgical removal of lymph nodes or radiation therapy. This causes noticeable swelling in the arm.
Compression garments can significantly reduce the swelling, prevent further fluid buildup and help prevent hospitalization. However, it wasn’t until January 2024 that Medicare finally started covering this essential treatment under Part B.
Those who chose Original Medicare must work with an approved DMEPOS supplier. Medicare Advantage members will need to find an in-network supplier.
Medicare Coverage in Older Women
Even though the risk for breast cancer increases with age, Medicare coverage does not change but the intensity of treatment can. Women over 70 are less likely to receive chemotherapy or radiation because the most common breast cancers are considered slow growing tumors. Some treatments may also be contraindicated because of other health conditions. (My mother was diagnosed at age 81 and the oncologist recommended no treatment. With her medical situation, he said she would likely die from some other cause and she did.)
Male Breast Cancer
Fewer than 1% of breast cancers in the US occur in men. In 2026, the American Cancer Society estimates about 2,670 men, usually between age 60 and 70, will be diagnosed with invasive breast cancer and about 530 men will die from breast cancer.
Medicare covers breast cancer in men just as it does in women, with one big exception. Medicare does not cover screening mammograms, probably because of the low risk.
Medicare Coverage of Experimental Procedures and Clinical Trials
Medicare covers procedures, drugs and devices that have been deemed reasonable and necessary. That disqualifies anything that is considered experimental or investigational.
However, Medicare will cover the routine costs of a qualified clinical trial, those items and services that are available to other beneficiaries. These include physician visits, diagnostic procedures, and hospital stays.
Find the current list of approved clinical trials on the Centers for Medicare and Medicaid Services website.
Breast cancer diagnosis and treatment is very individualized Medicare coverage can be complex and complicated As a breast cancer survivor, I have first-hand experience with most of the diagnostic and treatment options listed. My best advice: Confirm your coverage, ask lots of questions, discuss options, build a support network and know that this is a journey you cansurvive.
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