If your health plan covers mastectomy and you elect reconstruction, federal law requires it to cover breast prostheses too. The Women’s Health and Cancer Rights Act has set that floor since 1998. It does not set the detail: your share of the cost, replacement intervals, and whether a pocketed bra is included come from your plan.
Federal Law Requires Four Things of Plans That Cover Mastectomy
The law applies to group health plans and health insurance issuers that provide medical and surgical benefits for mastectomy. If your plan covers the mastectomy and you elect reconstruction, it must cover:
- all stages of reconstruction of the breast on which the mastectomy was performed
- surgery and reconstruction of the other breast to produce a symmetrical appearance
- prostheses
- treatment of physical complications of all stages of the mastectomy, including lymphedema
Deductibles and coinsurance can still apply, but must be consistent with what the plan charges for other benefits. Plans must describe these benefits in writing at enrollment and once a year after, so the answer is already in your plan paperwork. Certain church and government plans are exempt.
Key takeaway: Prostheses are one of the four categories the law guarantees.
The Law Says Prostheses; Your Plan Decides the Bra
The word bra does not appear in those four categories. Plans commonly implement the prosthesis benefit by covering pocketed mastectomy bras, which have sewn-in pockets that hold a breast form against the chest wall, but the plan’s documents decide that. Two women with the same surgery and different employers get different answers, and that is the part women find most frustrating.
Your summary plan description and the annual notice both address it, and member services can confirm how many bras are covered and how often.
A pocketed mastectomy bra is also not the same garment as a compression bra worn in the first weeks after surgery — different job, different point in recovery.
Key takeaway: The statute covers prostheses; your plan documents decide the bra.
Medicare and Medicaid Run on Their Own Rules
The Women’s Health and Cancer Rights Act does not bind Medicare or Medicaid. Medicare covers reconstruction after a cancer-related mastectomy, and Part B covers external breast prostheses, including a post-surgical bra. After you meet your Part B deductible, you pay 20% of the Medicare-approved amount.
Medicare pays only for items from a supplier enrolled in Medicare, and if that supplier does not accept assignment, meaning take Medicare’s approved amount as payment in full, you can owe the full charge. Ask about enrollment and assignment before a fitting.
Medicaid is set state by state, so its coverage of mastectomy products depends on where you live.
Key takeaway: Part B pays after your deductible, leaving 20% coinsurance; Medicaid depends on your state.
Replacement Intervals Come From the Plan, Not the Law
Medicare publishes a useful lifetime for each type of form: two years for silicone, six months for foam, fabric, or fiber-filled. It pays for one prosthesis per side per interval. Replacement sooner is allowed if the form is lost, irreparably damaged (ordinary wear and tear does not count), or your condition changes and needs a different item. Many private plans follow similar timelines, though the interval belongs to the plan.
Key takeaway: Under Medicare, two years for silicone and six months for foam or fiberfill.
The Prescription Is Where Claims Succeed or Fail
Yes, you need one. Medicare requires a standard written order, a signed order from the prescribing practitioner, for new prostheses and replacements, and most private plans want the same document. Insufficient documentation accounted for 50% of improper payments for breast prostheses in 2024, making this a paperwork problem more often than a coverage one.
Ask your doctor to name four things on it:
- a silicone breast prosthesis
- mastectomy surgical bras
- which side the surgery was on
- the breast cancer diagnosis
In billing terms, a pocketed mastectomy bra is L8000, the code for a bra with pockets to hold a form.
Fitting for a permanent form usually comes once the surgical site has healed, along a predictable week-by-week recovery.
Filing the claim, the paperwork, and what to do when one is denied are covered in our guide to paying for breast cancer care.
Key takeaway: Name the prosthesis, the bras, the surgical side, and the diagnosis.
Front Room Underfashions Submits In-Network Claims for You
Front Room Underfashions submits claims on your behalf for in-network insurance, and will check your benefits if you ask. The boutique is in network with most insurers and with Medicare, accepting assignment on most claims. If a prescription arrives wrong, the fitters will help correct it and work to get the claim paid, though no fitter can guarantee what an insurer pays.
Get the Prescription Right Before It Goes In
The prescription is the part worth slowing down for. Adding the diagnosis and the surgical side takes a minute in the office and weeks once a claim comes back without them.
Come See Us With Your Prescription and Insurance Card
The fitting is free. Bring your prescription and your insurance card, and see the mastectomy bras and breast forms we carry. Call ahead if you would like your benefits checked first.