Will Medicaid Pay for a Biopsy?

Medicaid covers biopsies in all states for beneficiaries under the age of 21. For those 21 and over, a biopsy may be covered in some states while not in others.

Medicaid coverage can vary by state (optional benefits), but there are certain services that are required by law to be covered in every state (mandatory benefits).

One of the federally mandated Medicaid benefits is EPSDT (Early and Periodic Screening, Diagnostic and Treatment) services for beneficiaries under the age of 21. A biopsy is a diagnostic test and thus falls under this mandatory benefit coverage category. 

But coverage of EPSDT (and therefore biopsies) is not federally required for Medicaid beneficiaries 21 and over. Each individual state is allowed to make its own coverage determination in this area. 

If you have Medicaid and need to know whether or not it will cover the cost of a biopsy, contact your state Medicaid program directly.  

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Does Medicare Cover Biopsies?

Some Medicaid beneficiaries may also have Medicare, which offers more comprehensive coverage of biopsies. Medicare typically covers medically necessary biopsies to detect cancer or other diseases. 

A biopsy performed at a doctor’s office or outpatient clinic will be covered by Medicare Part B. Part B has a standard monthly premium of $148.50 per month in 2021, a $198 annual deductible and typically a 20% coinsurance for costs after meeting the annual deductible. 

If performed at a hospital while you are an inpatient, a biopsy will be covered by Medicare Part A. Most people do not pay a premium for Part A. There is a deductible of $1,484 per benefit period but no coinsurance applies until day 61 of a benefit period. If you have Medicare and Medicaid, Medicare will pay for your biopsy first, and then Medicaid will help pay for the remaining out-of-pocket costs listed above.

Medicare Advantage (Medicare Part C) plans cover biopsies as well, because Medicare Advantage plans are required by law to provide all of the same benefits as Medicare Part A and Part B. If you have Medicaid and Medicare, you may be eligible for a type of Medicare Advantage plan called a Medicare Special Needs Plan (SNP), which can offer additional services and cover additional costs.  

What Types of Biopsies Are Covered?

There are several different types of biopsies, all of which may be covered by Medicare and/or Medicaid. 

• Bone marrow biopsies involve checking for blood cancers and other disorders using a needle to remove bone marrow.
  
  
• Endoscopic biopsies collect tissue samples from the lungs, colon, bladder, rectum and other organs to detect anemia, bleeding, inflammation or cancers of the digestive system.
  
  
• A needle biopsy collect a sample of cells beneath the skin to test for cancer, tumors, infections and cysts.
  
  
• Skin biopsies are used to test for skin cancer by shaving or cutting away a small piece of skin for analysis.

Surgical biopsies may be required when the test site is not easily accessible. A surgical biopsy may be performed on an inpatient basis, depending on how invasive the surgery is expected to be.