Even if Medicare will cover a biopsy; the words, “we need to schedule a biopsy to get a better look”, are words no one wants to hear. A biopsy itself is scary.
Most people know it’s a procedure to get a clear diagnosis of whether the area is cancerous or not.
With a biopsy, your physician removes sample cells from your body; then, later in a lab doctors determine if the tissue contains cancer. If the biopsy rules out cancer it can help your doctor determine the medical condition.
Medicare Can Cover a Biopsy
By now, most Medicare beneficiaries are aware of the Traditional Medicare benefits.
Medicare Part A covers any inpatient hospital admissions, diagnostic testing, lab work, inpatient treatment, medications while in treatment and hospice care. Part B covers all outpatient doctor’s visits, outpatient procedures, lab work, imaging, durable medical equipment, and physical therapy.
With both Plans, Medicare will cover all medically necessary palliative cancer care. This includes an inpatient or outpatient biopsy to get the cancer diagnosis.
Traditional Medicare covers 80% after the beneficiary meets the deductibles. The deductible is an out of pocket cost that Medicare doesn’t cover.
Original Medicare doesn’t cover prescription drug medications. With cancer this can cause some concern, as while chemo and radiation have coverage, oral medications won’t.
With most Medicare beneficiaries being on social security, living on a fixed income is stressful enough. Add in the scary cancer diagnosis, the last thing you need to worry about is if you can afford to pick up your prescription from the pharmacy.
By purchasing a Medicare Prescription Drug Plan (PDP), also known as a Medicare Part D Plan, oral cancer medications and post-cancer meds can be easily attainable.
A Medicare Part D Plan is a standalone drug plan by the private insurance companies in your area. You can buy one to go alongside your Traditional Medicare benefits. This will provide you the medically necessary drug coverage once getting the cancer diagnosis.
There are a variety of types of biopsies doctors use when trying to make a cancer diagnosis. Medicare will cover a portion of the cost of the biopsy; although, it needs to be medically necessary.
Depending on the area of concern will help your healthcare provider to determine which course of action is best for you.
Does Medicare Cover Needle Biopsy
Yes, if found medically necessary, Medicare will cover a portion of the cost. With a needle biopsy, your physician uses a needle to extract cells from the suspicious-looking area. Needle biopsies are most commonly done on suspicious breast lumps, enlarged lymph nodes, and tumors that can be felt through the skin.
Does Medicare Cover Skin Biopsies
When found medically necessary, Medicare will cover this biopsy. With a skin biopsy, the potentially cancerous cells are removed from the skin. Skin biopsies are done when attempting to diagnose skin cancers; such as basal cell carcinomas, melanoma and other types of cutaneous (skin) cancers.
Does Medicare Cover Bone Marrow Biopsy
Yes, Medicare will cover a bone marry biopsy if medically necessary. After abnormal bloodwork findings have come back, your physician may want to further investigate by taking a bone marrow biopsy. Your bone marrow is the soft tissue found within most of the bigger bones. Bone marrow itself makes most of the body’s blood cells. With a biopsy, the tissue is taken out and sent to pathology for further evaluation.
Does Medicare Cover Endoscopic Biopsy
If your doctor feels an endoscopic biopsy is medically necessary, Part B will cover 80%. An endoscope is a thin, flexible tube fixated with a light at the end. The tube goes down the throat or other areas of the body to further see an area.
A special tool goes through the scope to collect small tissue samples for analyzation. Most commonly, endoscopic biopsies collect tissue from the abdomen, bladder, lungs, joint space or colon to see if these organs have cancerous cells.
In some cases, if the other biopsy results have come back as inconclusive then a surgical biopsy must be performed. During a surgical biopsy, a portion of the worrisome tissue from the mass or lump in question is taken out.
After being in the lab, your doctor will have more answers about your condition.
The Purpose of a Biopsy
If the cells obtained are cancerous, the results from the biopsy tell your physician exactly what type and cancer location. Medicare will cover a medically necessary biopsy.
Biopsies also let your healthcare provider know how far along the cancer is. The grade of cancer ranges from 1 to 4. In some cases, doctors use stage 0.
Here’s a breakdown of the various cancer grades:
- Stage 0: cancer cells are in a place where they originated and have not yet spread. This grade has a high cure success rate and most commonly resolved after removing the tumor in its entirety.
- Stage 1: cancer cells look very similar to normal cells. They have not yet spread to the lymph nodes or other areas and are slow-growing in nature.
- Stage 2: cancer cells have spread into the lymph nodes or other nearby tissues. The cancer cells are visibly abnormal and growing more quickly than your physician would like.
- Stage 3: cancer cells are more advanced have spread farther than Stage 2 (possibly to the lymph nodes) and the cancers or tumors are generally larger in size.
- Stage 4: this is the worst stage to have and is metastatic cancer. With stage 4 cancer, the cells are more widespread to additional organs and other distant areas of the body. This stage is aggressive and fast-moving.
Biopsy Treatment Plan
With a lower grade tumor, the outlooks are obviously better. With higher grade cancer, there’s the chance for it growing more aggressively.
Depending on what grade cancer you have, that will determine the intensity of the treatment.
Doctors look at the stage of cancer, but other factors such as type, age, and overall general health are important. When your healthcare team is formulating your individual treatment plan, they take these things into consideration.
More Information on When Medicare can Cover a Biopsy
While Traditional Medicare offers excellent healthcare coverage, not all benefits have coverage.
There are additional insurance plans outside of Medicare that many buy for extra healthcare benefits.
Medicare Advantage Plans: are Medicare Replacement Plans and will take over Traditional Medicare benefits. It offers everything Part A and Part B provides but has the benefits of lower deductibles, copayments and in some cases includes coverage for dental and vision.
Medicare Advantage Plans come from private insurance carriers in your area. While it may appear cheaper in the long run, plan limitations, prior-authorizations, and in-network only healthcare coverage is a downfall with these policies.
Medicare Supplement Plans: Like Medicare Advantage, Medicare Supplement Plans are a stand-alone plan by insurance providers. The big difference with Medicare Supplement Plans is there’s a variety of plans.
Also, different from Advantage Plans, Supplement Plans work in conjunction with Traditional Medicare. While the insurance premiums may be slightly higher, over time, the out of pocket costs end up cheaper with Medicare Supplement Plans.
These plans tend to not only be more beneficial for retirees but also more popular.
Medicare Supplement to Help Cover Biopsy
By combining your Traditional Medicare benefits alongside a Medicare Supplement Plan and a Prescription Drug Plan, recipients can get superlative coverage with minimal out of pocket costs.
We here at MedicareFAQ we love helping Medicare beneficiaries secure the best possible coverage at the most affordable costs.
For more information, fill out our online forms or contact our tollfree number today. Our licensed insurance agents are ready and more than happy to offer support and guidance when facing the confusing world of insurance.