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What Biopsies Will Medicare Cover

Medicare can cover a biopsy to find out whether you have cancer or another health condition. Your costs will depend on several factors. Things that can influence cost include location, supplemental coverage, and type of biopsy.

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Will Medicare Cover a Biopsy?

Medicare covers medically necessary procedures to diagnose and treat health conditions, including biopsies. Biopsies are often associated with cancer, but they can also help your doctor identify other conditions such as infections or inflammation.

During a biopsy, your doctor will surgically remove a small amount of tissue and send it to a lab for testing. You may be under anesthesia. Most biopsies are outpatient. You may get bills from doctors, facilities, and labs for your procedure.

Biopsies performed in doctors’ offices or at outpatient centers are covered by Medicare Part B, Medicare’s medical coverage. If your doctors accept Medicare assignment, you won’t have a higher fee. But, before Medicare pays, you must meet the annual part B deductible.

If you are an inpatient at a hospital, Medicare Part A covers biopsies. Medicare Part A also has a deductible. But after you’ve met that deductible, Medicare Part A pays 100% of the biopsy’s cost.

Does Medicare Cover Needle Biopsies?

Needle biopsies involve inserting a needle into your body to get cells from your muscles, bones, or organs for testing. Needle biopsies may detect cancer or diagnose other conditions such as infections or inflammations.

There are two types of needle biopsies: Fine needle aspiration and core needle biopsy. Medicare covers both kinds of needle biopsies. Coverage is the same as for other types of biopsies Medicare also covers anesthesia and imaging tests such as CT scans, which your doctor may administer before or as part of the biopsy procedure.

Does Medicare Cover a Prostate Biopsy?

If you’re 50 or older, Medicare covers an annual prostate-specific antigen test to screen for prostate cancer. If your results show higher than normal levels of the antigen, your doctor may order a biopsy to find out whether there are any cancer cells present.

As long as they are medically necessary, prostate biopsies are covered by Medicare, just like any other biopsy. Your biopsy will most likely be performed on an outpatient basis, and it will, therefore, fall under Part B’s medical coverage.

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Does Medicare Cover Breast Biopsies?

Medicare covers some screenings for breast cancer. Women over 40 who are on Medicare can have yearly screening mammograms free of charge.

Medicare also pays for a manual breast examination every two years as part of a well-woman exam. If a breast examination or mammogram reveals a lump or abnormality in your breast, your doctor may order a biopsy.

If your biopsy occurs at a doctor’s office or outpatient center, Medicare pays part of the cost. You pay the rest if you don’t have a Medigap plan. With Medigap coverage, your biopsy could have total coverage.

Does Medicare Pay for an Oral Biopsy?

Oral biopsies help doctors diagnose cancers in your mouth or oropharynx – the part of your throat behind your oral cavity. Your doctor or dentist may refer you to a specialist for evaluation if they suspect you have mouth cancer.

Medicare doesn’t cover dental care or cancer screenings at a dentist’s office. But, Medicare does cover biopsies to diagnose cancers of the mouth. Medicare pays for oral biopsies in the same way as other types of biopsies.

Do Medicare Advantage Plans Cover Biopsies?

If you have Medicare Advantage, your plan will cover biopsies, just the same as if you had Medicare. But, private companies that sell Medicare Advantage establish deductibles and copays.

That means your costs depend on the specifics of your plan. Unlike Medicare, Medicare Advantage plans have doctor networks. To keep your costs down, be sure the doctors are in your plan’s network.

Do Medigap Plans Cover Biopsies?

Medigap lowers your out of pocket costs for services and procedures that are covered by Medicare. All Medigap plans cover biopsies. But with some plans, you will be responsible for a flat copay or a percentage of the bill.

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For example, if you have Medigap Plan G, your plan will pay all the Part B charges that Medicare doesn’t after you meet the deductible.

FAQs

Does Medicare cover bone marrow biopsy?
Bone marrow biopsies can diagnose blood cancers such as leukemia. Medicare will cover a bone marrow biopsy as long as it is medically necessary.
Does Medicare cover skin biopsies?
Your doctor may order a skin biopsy if you have abnormalities on the surface of your skin that could indicate cancer. Medicare does cover skin biopsies, as well as treatment for skin cancer.
Does Medicare cover endoscopic biopsy?
Endoscopic biopsies can diagnose cancer in tissue inside the body, including lung, bladder, and colon cancer. A doctor inserts a long thin tube through an incision or opening in your body and removes a small amount of tissue for testing. Medicare does cover endoscopic biopsy, whether you receive a biopsy as part of a hospital stay or as an outpatient. Coverage is the same as for other types of biopsies.

How to Get Help Finding Medicare Coverage for Biopsies

Medicare can be confusing, even if you’ve done your homework. An agent can help you sort through the options and choose a policy that fits your budget and gives you the best coverage possible.

At MedicareFAQ, we help you every step of the way. Our agents are always available to answer questions and explain your options. Give us a call or fill out our form to get started with a free quote.

David Haass

David Haass

David Haass is the Chief Technology Officer and Co-Founder of Elite Insurance Partners and MedicareFAQ.com. He is a member and regular contributor to Forbes Finance Council and stay up-to-date with the latest Medicare trends and changes. He holds a Bachelor of Science in Business Administration and Management from the University of Florida.

22 thoughts on "What Biopsies Will Medicare Cover"

  1. Need a breast biopsy I have Medicare/ plan N
    2023 first time for new year
    Using my insurance
    Will Medicare pay for the biopsy and does my plan N pay anything

    1. Hi Lois! Since this is the start of a new year, you will be responsible for your Part B annual deductible before any coverage goes into effect. Once your deductible is paid, Medicare Part B will cover 80% of your costs. Then, your Medicare Supplement Plan N will cover the remaining 20% of your bill. However, with Plan N, you may be required to pay a copayment for the biopsy. So, your out-of-pocket costs will include the deductible and any applicable copay.

  2. I will have to do an oral biopsy in December. currently I medicate A and B . How much will I pay out of pocket considering I only paid $30 total this year?

    1. Hello! If you only have Original Medicare, you will be responsible for the Medicare Part B deductible ($233 in 2022) and then 20% of your total costs after you meet the deductible.

  3. I have a follow-on question. When you say yes, Medicare or the supplement covers that, does that include the lab costs? Because it seems that lab costs, which are high, are not always covered.

    1. Lab costs are covered when medically necessary for the procedure or condition being treated. Often, your physician may order more labs to rule out additional issues that may not be medically necessary for the condition at hand, but for precautionary measures. In this case, to avoid unexpected costs, you should speak with your physician a out the medical necessity of your lab work.

  4. If I have a biopsy of my lip and it isn’t cancer will Medicare still pay. Does Medicare pay for the biopsy to be tested

    1. Hi Valerie! Yes, as long as your doctor says the biopsy is medically necessary then Medicare will cover it.

  5. I will be having surgery to remove tumors from liver. My Dr. would like to use Guardant360 liquid biopsy to preempt possible recurrence that would not show with PET,MRI or CT screening.
    Would this be covered with a Medicare Advantage Plan, Aetna PPO Plan.

    1. Hi Gregory! Since each Medicare Advantage plan comes with its own Summary of Benefits, you would need to contact the carrier directly to find out if a service is covered.

  6. My Mom just discovered a lump at the top of her breast on the chest wall. Her Doctor ordered up a mammogram and sonogram. Now they said she needs a needle biopsy performed. Does Medicare cover this biopsy?

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