Medicare can cover a Pancreas Transplant; however, like many other things Medicare covers, certain requirements must be met. It’s your responsibility to understand how your coverage works. The more you know, the further your coverage will go.
Pancreas Transplant and Medicare Coverage
Medicare Part A consists of your hospital benefits. This is coverage on care and certain durable medical equipment (DME) during hospital admission.
Part B consists of your outpatient benefits. This coverage is for outpatient procedures as well as certain durable medical equipment.
Once you meet the deductible, Medicare covers 80%. This leaves the remaining 20% coinsurance cost left for the Medicare beneficiary to pay.
According to Medicare, pancreas transplants qualify for Medicare coverage under these following circumstances:
- If the transplant is deemed medically necessary
- The individual must have type 1 diabetes with uncontrollable medical complications
- A patient must have an endocrinologist for a year; all the optimum treatments had no success.
- Mental clearance so the transplantee understands and accepts the risks coming with the complex surgery. Must understand aftercare needs with lifetime immunosuppressive drugs.
- Those with End Stage Renal Disease (ESRD) and need a kidney transplant; a pancreas transplant can happen at the same time.
- Medicare can cover a pancreas transplant if the individual has already had a kidney transplant.
- In some cases, without a kidney transplant, you can qualify for a pancreas transplant. However, you’ll need to address this with your healthcare provider to see if you qualify for eligibility.
Part D and Pancreas Transplant Coverage
Generally, neither Medicare Part A nor Part B has prescription drug coverage; however, after a transplant, there are certain exceptions that apply.
Immunosuppressive drugs have coverage after a transplant with no limitations. Additionally, if you become disabled due to the organ transplant, then Medicare will provide coverage post-implant surgery.
The exception being a kidney transplant. Medicare Part B will only provide immunosuppressive drug therapy for 36 months after the time of transplant. You must be eligible for Medicare due to End Stage Renal Disease (ESRD).
Also, if the pancreas transplant happened after the kidney transplant. Additionally, Medicare Part B benefits cover post-op follow up visits, labs, imaging and additional follow up care.
Pancreas Transplant Description
A pancreas transplant can be an option for those diagnosed with type 1 diabetes. With the organ being transplanted it actually offers a potential cure for the disease altogether. The American Diabetes Association says the transplant could improve patients quality of life.
With a successful transplant; patients can live a more active life, have fewer dietary restrictions, and insulin injections can be forgotten. Additionally, having a pancreas transplant can help damage caused to the kidneys and other organs caused by type 1 diabetes.
A pancreas transplant involves harvesting a healthy pancreas; this is either from a partial pancreas from an alive donor or a dead person’s completely healthy pancreas.
Pancreas transplants go to individuals suffering from Type 1 diabetes; who also suffer from chronic kidney disease or other life-threatening consequences.
Type 2 diabetics generally aren’t candidates for pancreas transplants as their body has an inability to use insulin properly. It’s not due to the pancreas being unable to produce insulin so a transplant would be completely ineffective.
There are three main types of pancreas transplants:
- Pancreas transplant alone: Individuals suffering from type 1 diabetes; with frequent and severe hypoglycemia but also has adequate kidney function.
- PAK (pancreas after kidney transplant): A patient has either a living or dead kidney donor transplant and then they receive a pancreas transplant.
- SPK (simultaneous pancreas-kidney transplant): With end-stage renal disease being one of the most serious complications from type 1 diabetes, oftentimes a kidney transplant is a must.
Kidney Transplant and Pancreas Transplant
If a kidney transplant is prior to a pancreas transplant, antirejection medication is a must, as well as insulin. Without a pancreas transplant, there’s a good chance of diabetes damaging the new kidney as well as other vital organs.
With most simultaneous pancreas-kidney transplants, any new damage is prevented as a complication from diabetes. Additionally, insulin can be eliminated altogether. A physician preference would be a kidney and pancreas from the same donor.
An SPK is the best-case scenario or individuals suffering from diabetes. The pancreas is a vital organ located in your abdomen that has multiple functions.
The organ itself produces fluid to help food digest. It also produces a hormone called glucagon, which is necessary to control your blood glucose (blood sugar) levels. Having an inadequate amount of blood sugar can result in diabetes.
There are two types of diabetes:
Type 1 diabetes: with type 1, the body doesn’t provide insulin; or, if it does provide insulin it’s an insufficient amount.
Type 2 diabetes: with type 2, the body doesn’t respond as well as it should with the produced insulin. Later on, down the line, type 2 diabetics bodies will eventually stop making enough insulin altogether.
Additional Help Understanding How Medicare Covers a Pancreas Transplant
Traditional Medicare benefits only cover 80%; the remaining 20% can easily add up, especially after a major surgery like a transplant. There are Medicare Supplement Plans available that are offered from the local insurance companies in your area.
By purchasing a Medicare Supplement Plan and a Part D Plan, you can save thousands of dollars on healthcare costs. In some cases, other than the monthly insurance premiums, there may be no out of pocket medical costs at all!
We here at Medicare FAQ are specially trained with the goal of getting your optimal insurance coverage at minimum prices. Having the best health insurance coverage is one way to ensure a longer and healthier life!
Call a broker at the number above or fill out an online rate form and discover your best policy.