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Understanding Medicare Coverage for Biopsies

A biopsy is a procedure that removes cells or tissue from the body, creating a sample that undergoes further examination from a pathologist, who reviews the sample to help diagnose a condition or clarify a treatment plan. Many biopsies can be performed on most parts of the body. Medicare covers the procedure for those who qualify. This article provides an overview of different biopsies, current Medicare policies on biopsies, Medicare coverage, including out-of-pocket costs, and estimated costs for individuals not covered by Medicare or commercial insurance.

What is a biopsy?

The Centers for Disease Control and Prevention (CDC) defines a biopsy as “a minor surgery to remove body fluid or small pieces of tissue.” The procedure helps physicians diagnose abnormal conditions and aids in the development of treatment plans. Most involve removing a small section of skin, tissue, bone marrow, or organ, which is sent to a pathologist for analysis. The procedure is often done to diagnose and treat specific cancers and other conditions.

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Types of biopsies

The following is a list of biopsy types and descriptions:

  • Bone marrow biopsy uses a needle to remove marrow and is used to check for blood cancers and other disorders.
  • Endoscopic biopsy gathers cell and tissue samples from your lungs, colon, bladder, rectum, and other organs using a thin, flexible scope.
  • Needle biopsy samples suspicious tissue from areas such as a breast or lymph node.
  • Skin biopsy helps to diagnose skin cancers. Your doctor will shave, punch, or excise (cut away) a bit of tissue for lab analysis.
  • Surgical biopsy occurs when the doctor makes a skin incision to observe suspicious cells and removes all or part of them. Some of these procedure require the patient to stay in the hospital overnight.

What to expect during a biopsy?

Biopsies are considered an invasive but low-risk procedure. Patients may undergo testing while wearing a surgical gown or, in some cases, lose fitting clothing. The procedure is most often performed in a doctor's office, although some are performed in an outpatient surgical suite. Patients may feel little pain during the procedure as appropriate anesthesia is used.

Most patients can go home the same day, although some surgical procedures may require an overnight hospital stay. Review the protocol with your medical provider to anticipate specific steps.

Test result time can vary after the procedure. Some tests provide information within a day, while many take a week or more. Your medical provider will tell you when you can expect the results.

Biopsy costs for individuals enrolled in Medicare

Individuals enrolled in Medicare typically have coverage for biopsies. Medicare pays 80% of the approved fee from Medicare Part B, leaving the patient responsible for 20% after satisfying the Medicare Part B deductible. Recipients enrolled in a Medicare Supplement plan may have this 20% cost covered, so they should review their plan for specifics.

Medicare Advantage Plans cover their recipients differently, often charging a copay or a co-insurance percentage. These members should review their plans for coverage specifics and verify if pre-approval is necessary before the procedure. They can review their plan's Evidence of Coverage book or call their member services to review.

Cost of a biopsy for individuals enrolled in commercial insurance

Costs can vary considerably for individuals with commercial insurance, especially if the policy has a deductible of as much as $5,000–6,000 annually. Individuals should contact their plans for more information.

Cost of a biopsy for individuals without insurance

Costs for those without insurance can be expensive. For example, be prepared to pay between $155 and $1,100 for a skin biopsy, with the price on the lower end for the procedure performed in a doctor's office and the higher performed in a surgical suite. Breast biopsies can range between $1,100 and $5,100, while a liver biopsy may vary between $2,100 and $7,100.

How to apply for financial aid to help with costs

Some financial aid programs help with the out-of-pocket costs of biopsies. Medicare recipients can review programs and apply online through Social Security; call 1-800-772-1213 (TTY 1-800-325-0778) between 8 a.m. and 7 p.m. local time, Monday through Friday, to apply over the phone or make an appointment to apply in person at a local Social Security office. Non-Medicare recipients can inquire about patient financial assistance through their doctor's office or local hospital.

Biopsy coverage details and limitations

Medicare recipients should be cautious about some biopsies as they may involve non-covered procedures. For example, Medicare doesn’t cover dental care or cancer screenings at a dentist’s office. However, Medicare will cover biopsies to diagnose cancers of the mouth. Medicare pays for oral biopsies in the same way as other types of biopsies. In addition, newer cancer or chronic procedures may be so new that Medicare cannot provide coverage until the CDC accepts the procedures.

For help with these questions, you can call Medicare anytime at 1-800-MEDICARE (1-800-633-4227). The TTY (Teletype) number is 1-877-486-2048. If you have a Medicare Advantage Plan, you should contact the member services number for your plan, which is provided on your member ID card.

The member services can clarify if the procedure is covered and also review possible pre-authorization requirements needed by your plan.

Documentation of conversations with medical providers and health plans

Documenting all conversations with your medical providers and health insurance plans is advised. These notes can be helpful if you have additional questions, need a review of your procedure, or understand if you need assistance for recovery. You should also keep copies of all bills received and explanations of payment documents. These notes can help review actions taken and steps required to resolve any billing issue that might arise.

Medicare appeals process

Medicare recipients have Appeal Rights as outlined in the Centers for Medicare and Medicaid Services (CMS) as follows:

  • Recipients with Original Medicare A and B, including those enrolled in a Supplement or Medigap Plan, should review their Medicare Summary Notice (MSN). If they disagree with the payment provided, they can file an appeal within the timeline provided on the MSN. If the deadline was missed, they can attempt a review by explaining good cause as the why the deadline was missed.
  • To initiate an appeal, recipients should complete the Redetermination Request Form and send it to the company that handles claims for Medicare. Their address is listed in the 'Appeals Information' section of the MSN. Send a written request to the company that handles claims for Medicare to the address on the MSN.
  • Individuals with a Medicare Advantage Plan can follow the appeal instructions written on their Explanation of Benefits statement or call member services for appeal instructions.

If you have a Medicare Advantage Plan, you can call the member services phone number on your ID card and receive instructions on your plan appeal rights.

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