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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.

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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.

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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.

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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.

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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.

Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare guru serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

22 thoughts on "Does Medicare Cover Prosthetics"

  1. I am a below the elbow right arm amputee which occurred a few years ago in a car accident. I love in California and I am a Medicare HMO patient with medi-cal. I am requesting a cosmetic prosthetic which will be easier for me to handle since it is light weight. The loss of my arm, the comments, the stares causes me great anxiety and depression. I was referred to a contracted prosthetic company. I now have been waiting months to get a decision whether or not the Medicare HMO will authorize it. What are my tights? Do they have a responsibility to provide this prosthetic?

    1. Hi, sorry to hear about your accident. Often, Medicare will not cover the costs of cosmetic medical equipment. However, each case is determined on a case by case basis. If you have not heard back about a decision after two weeks, it is recommended that you contact your insurance carrier for more details.

  2. MY grandma is a below-knee amputee she received her prosthesis 6 years ago since receiving it she has lost 50 pounds she does not walk far distances but does require a good fit to get in the bathroom and do little things around the house. she suffers from fatigue, weakness, and shortness of breath medicare provided her with a power wheelchair 2 yrs ago. The current prosthesis is out of warranty she is wearing 15 ply socks and still struggles to keep the leg on due to the weight loss. She is needing a new prosthesis or at very least a replacement socket for transfers and limited ambulation. Will Medicare cover a replacement prosthesis or socket with her having a power chair?

    1. Katrina, this is something you would need to speak with her doctor about. Her prosthesis would be covered if deemed medically necessary by her doctor. It would be up to the doctor if a new prosthesis is needed.

  3. Does my Cigna Medicare Rx drug plan cover a cranial prosthesis for Alopecia due to cytotoxic drug used in Chemotherapy for cancer?

    1. Marilyn, thank you for the question. Unfortunately, Medicare Part D does not cover cranial prosthetics. Part D plans only cover certain prescription medications found on the plan’s formulary. Medicare part B also will not cover cranial prosthesis as Medicare does not cover services that are used for cosmetic purposes.

  4. Does Medicare pay for a second AK prosthetic leg after only 2 years when patient has gained weight. My sister prosthesis no longer fits well and she has a lot of phantom/ nerve pain when trying to wear it

    1. Hi Linda! Yes, as long as her doctor says it’s medically necessary, Medicare should cover it. Your best option is to have your sister contact Medicare directly while she is with her doctor to discuss what documentation they would require.

  5. What happens when the person who needs a prosthetic leg is on a disability income, which translate to no money whatsoever to pay for anything and is currently hobbling around on a leg that is black, blue,mpussing and bleeding?

  6. i have a patient who is in skilled nursing facility under MedA skilled. the prosthetic company will not give the patient their prosthetic until he is off med A or the facility agrees to pay. I am under the understanding that it can still be billed to medB even if he is under services of medA

    1. Hi Theresa! The prosthetic is considered Durable Medical Equipment, which would fall under Part B. The prosthetic company cannot bill the Skilled Nursing Facility since they are only providing inpatient services under Part A. Your patient would need to have the prosthetic “prescribed” by a physician at an outpatient facility so the prosthetic company can bill the outpatient facility under Part B. The prosthetic company cannot get paid by Medicare under Part A for services rendered at an inpatient facility. In some cases, an inpatient facility can bill for Part B services. However, a DME provider cannot bill Part A for Durable Medical Equipment. I hope this helps!

  7. Does Medicare cover a nurse to do intermittent catheterization for a home bound patient age 82 with urinary retention, ordered by a urogynecologist, for a short term period while the cause is further worked up by physicians? She cannot catheterize herself.

    1. Hi Kirsten! Yes, as long as the urogynecologist says it’s medically necessary and presents Medicare will the correct documentation and treatment plan.

  8. does medicare cover any of cost for bathroom remodel i.e. seat height toilet, walk in shower for an amputee. my brother is having leg amputed this wednesday 6/17/2020 due to infection in leg. Also a new mattress will be needed for his bed at home when he returns. his mattress on the bed now is very high from ground. does medicare cover any of this cost? thank you

    1. Hi Susan! Medicare does cover some Durable Medical Equipment for bathroom safety. As long as your doctor finds it medically necessary, Medicare may help pay for the cost or reimburse you for some of it. I would start by speaking to your doctor about what documentation they can provide that will help show Medicare it’s medically necessary. This works the same with the mattress. I hope this helps!

      1. Hi Jen! Medicare will cover a prosthetic leg if it’s surgically implanted in an inpatient or outpatient facility. If it’s done in an inpatient facility, then it falls under Part A. If it’s done in an outpatient facility, it will fall under Part B.

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