Does Medicare Cover Prosthetics

Original Medicare will cover a variety of prosthetics to replace a body part or function when medically necessary. When you think of prosthetics, arms and legs may be the first things that come to mind. However, prosthetic devices range from things like artificial teeth, eyes, and facial bones, to artificial hips, knees, joints, extremities, and more.

Prosthetic devices are covered under the durable medical equipment benefit through Medicare Part B. Below, we discuss the details of Medicare coverage and guidelines for orthotics and prosthetics.

Are Prosthetics Covered by Medicare?

Original Medicare provides coverage for prosthetic devices such as enteral and parenteral nutrition equipment & supplies, tracheostomy care supplies, urological supplies, cardiac pacemakers, speech aids, scleral shells, etc. Additional examples include:

• Artificial limbs
• Breast prostheses after a mastectomy
• Cochlear implants and certain other types of surgically implanted prostheses
• Ostomy bags and supplies
• Eyeglasses or contact lenses after cataract surgery

Original Medicare is made up of Medicare Part A and Part B. Each part of Medicare provides different coverage and requires you to pay a different coinsurance amount depending on your care. Here’s how Medicare covers prosthetics:

• Medicare Part A covers the costs of prosthetics when dealing with inpatient procedures (resulting in a hospital stay).
• Most commonly, Medicare Part B will cover the costs of prosthetics with outpatient procedures.
• Furthermore, Medicare Supplement plans (Medigap) can help cover expenses that you might otherwise pay for out of pocket with Original Medicare alone.
• Some prosthetic devices may also be covered by Medicare Advantage plans.

Since each situation is unique to the beneficiary, it’s important to talk with your doctor to see how Medicare will cover your prosthetics. It’s also worth noting that in order to use your Medicare coverage, you must be receiving healthcare from a Medicare-approved doctor or facility.

The Medicare guidelines for orthotics and prosthetics are straightforward. Still, we’ll continue to break down some of the most common prosthetic devices covered by Medicare for a clearer idea of how your coverage will work.

Does Medicare Cover Prosthetic Legs?

Original Medicare does cover prosthetic legs when medically necessary. Medicare Part B covers the surgery cost if it’s done in an outpatient setting, while Medicare Part A covers costs if it’s done in an inpatient setting.

Remember, you must get your prosthetic leg through a supplier that participates in Medicare to receive coverage. If the prosthetic leg is covered by Medicare Part B, you’ll pay 20% of the cost plus your annual Medicare Part B deductible.

If covered by Medicare Part A, you’ll be responsible for the Medicare Part A deductible plus any applicable copayments and coinsurance. If you have a Medicare Supplement plan, it will help cover most, if not all, of your required cost-sharing. However, if you are enrolled in a Medicare Advantage plan, your specific plan will have its own out-of-pocket requirements you must meet.

How Much Does a Prosthetic Leg Cost?

Many factors affect the cost of a prosthetic leg, including your age, size, typical activities, health, and materials, and required features. Additionally, extra features you add to your prosthetic that is not considered medically necessary can add additional costs to you that will not be covered by your Medicare health insurance. As a result, a prosthetic leg can have an average cost of anywhere from $5,000 to $50,000.

Furthermore, your costs can vary depending on your coverage, whether or not your healthcare facility accepts Medicare, and fees from your doctor. For a more accurate picture of what your costs might be, it’s always important to speak to your healthcare provider.

How Often Does Medicare Pay For Prosthetic Legs?

Medicare covers replacement prosthetics every five years. In addition, Medicare also covers polishing and resurfacing twice each year. Medicare provides coverage for both long-term care as well as helping you maintain your devices.

The Medicare Artificial Legs, Arms, and Eyes benefit (Social Security Act §1861(s)(9)) covers lower limb prostheses. You can receive reimbursement if the reasonable and necessary (R&N) requirements according to your Local Coverage Determination (LCD) are met as well as meeting additional requirements as outlined by the Centers for Medicare & Medicaid Services (CMS):

• Your device has damage or wear and is in need of restoration.
• Your prosthesis adjustment is needed due to a change in your condition or to simply improve its function.
• Several other items may be available for reimbursement, including your device’s evaluation, fitting, the cost of labor and parts for specific components, repairing normal wear and tear within 90 days of receiving your device, and other adjustments.

How Much Does a Prosthetic Arm Cost?

The average cost of a prosthetic arm can be difficult to pinpoint for a number of reasons. Like prosthetic legs, there is a wide array of options and features for prosthetic arms. Due to this, the cost can range from around $3,000 to $30,000. Advanced myoelectric arms costs can range even higher, falling between $20,000 and $100,000+ depending on the technology it uses. Medicare may pay for advanced features, but only if they are medically necessary.

Original Medicare covers prosthetic arms the same as legs. Through Medicare Part B, you pay your annual deductible then, you are responsible for 20% of the costs. Unless, of course, you have a Medigap plan to help cover these costs. If hospitalized, Medicare Part A will cover your costs after you pay the per-occurrence deductible and applicable copayments and coinsurance.

Does Medicare Cover Cranial Prosthetics?

Unfortunately, Original Medicare does not cover cranial or hair prosthetics unless it’s necessary for treatment. Since a wig won’t improve your health condition, it’s unlikely that insurance will cover these costs.

However, the cost of wigs for cancer patients can be a tax-deductible expense, so save your receipts. Furthermore, if you have a Medicare Advantage plan, you may get reimbursement for one wig.

If your condition creates hair loss and you wish to receive a cranial prosthetic, there are several organizations and programs your physician may be able to connect you with that provide low-cost or donated cranial prosthetics.

Does Medicare Cover Cochlear Implants?

Medicare covers cochlear implants to improve hearing for deaf individuals. Implants work differently than hearing aids and can cost as much as $100,000 without insurance. But you can expect to pay much less if you have Medicare. Your Medicare Part B covers implants inserted in a healthcare provider’s office or outpatient facility.

Medicare will pay 80% of the Medicare-approved rate after your Part B deductible for the implants and surgery. If you have a Medigap policy, the additional 20% may be covered by your plan.

Does Medicare Cover Prosthetic Eyes?

Prosthetic eyes are covered by Original Medicare if your doctor deems them medically necessary.

Similar to other prosthetic procedures, your Medicare Part B will cover the surgical procedure to insert the implant into the orbital socket, so long as it is outpatient care. Once you meet the Medicare Part B deductible, Medicare pays 80% of the cost. You will be responsible for the remaining 20%, however,  if you are enrolled in a Medicare Supplement plan, your out-of-pocket costs may be lower.

Does Medicare Cover Breast Prosthetics?

Medicare covers surgically implanted breast prostheses after a mastectomy thanks to Medicare Part B. Medicare Part B also pays for external breast prostheses, bras, and post-surgery camis. Your Medicare Part A will cover surgically implanted breast prostheses following your mastectomy if your surgery is an inpatient procedure.

But, you must use a supplier that participates in Medicare, and custom breast prosthetics are not covered. External breast prostheses need replacement periodically, and Medicare will pay for replacement devices.

Medicare adheres to this coverage schedule:

• One silicone breast form every two years, or one foam breast form every six months
  • If you had surgery on both breasts, Medicare would pay for two
• Mastectomy bras with a doctor’s prescription have coverage for about 4-6 bras each year
  • Medicare may cover new bras because of changes in your weight or other reasons
• Up to three camis a month, if necessary

Medicare covers standard external breast prosthetics, but like any other device, they must be medically necessary. Devices for cosmetic reasons aren’t covered by Medicare.

How To Get Medicare To Cover Prosthetics

Getting Medicare to cover the cost of your prosthetics is simple, and we can help. The Medicare guidelines for orthotics and prosthetics demonstrate that if your device is medically necessary, Medicare will help pay for them. Our team can help you find a plan that fits your health and budget needs. Call us today at the number above or fill out an online rate form to find and compare plans in your area.