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Medicare Part B will cover certain prosthetic devices needed to replace a body part or function.
Prosthetics are considered “durable medical equipment” under Medicare Part B coverage.
In order to have your prosthetic devices covered, you’ll probably need to meet certain criteria.
Medicare Advantage, also known as Medicare Part C, may also cover prosthesis.
If you’re new to the world of Medicare, it isn’t always easy knowing what your plan will or will not cover. The general rule of thumb is that Medicare will only cover what it considers to be medically necessary. However, figuring out what is or isn’t medically necessary can be tough.
Take, for example, prosthesis and prosthetic devices. Loss of a limb or other body part for any reason is devastating. Being able to replace that limb or body part can help you feel a sense of cosmetic and physical normalcy. It can also help you function as you had before the loss.
If you’re in need of a prosthetic device, you may be wondering, “Does Medicare cover prosthesis?” The good news is that, yes, in many cases, prosthesis is covered by Medicare. At MedicareInsurance.com, it’s our mission to help you discover what is or isn’t covered by your Medicare plan. Today, we’re looking at Medicare’s coverage of prosthesis.
Those in need of prosthetic devices will be happy to learn that Medicare does indeed cover most prosthetic devices. The keyword here is “most”, as Medicare will only cover prosthetics that are approved as being “medically necessary”. This means that the prosthetic devices are needed to help you recover some type of crucial function in everyday life.
Medicare Part B helps cover the cost of prosthesis once you’ve met your Part B deductible. This means that Medicare Part B will cover 80 percent of the Medicare-Approved Amount for external prosthetic devices, while you’ll cover 20 percent. Some of the prosthetics that are covered by Medicare include:
In some cases where a patient is seeking a lower-limb prosthetic device, such as a prosthetic leg or other prosthetic limbs, such as prosthetic feet, the state you live in may require prior authorization before Medicare will pay. You’ll also need to speak with your doctor or healthcare provider to make sure they’ll even cover the cost of your device.
Medicare will not cover any item, procedure, or service that it sees as cosmetic, or not “medically necessary”. This includes prosthetics that serve no function other than improving one’s appearance.
Many of the prosthetic devices that aren’t covered by Medicare are fairly obvious. For example, if you’re looking to get cheek fillers or a cleft implant in your chin to fight off the signs of aging, Medicare will not cover these devices. These types of prosthetic devices serve no purpose other than altering appearance, and therefore are not considered medically necessary.
You’ll notice that breast prostheses are mentioned above as covered prosthetics under Medicare. Coverage of breast prostheses comes with a caveat – they’re only covered if you’ve had a mastectomy to remove cancer from one or both breasts. If you’re looking to get augmentation for the simple reason of just having it done, Medicare will not cover the surgery or the implants because the procedure is being performed for cosmetic reasons as opposed to medical.
If you have a Medicare Advantage plan, or you’re considering enrolling in one, and you’re wondering whether or not they cover prosthetic devices, wonder no more. Much like Original Medicare, Medicare Advantage plans can help you cover the cost of prosthesis. Though these plans are offered by private providers, they cover the same services that are covered by Medicare Part A and Medicare Part B. This includes the cost of medically necessary prosthetic devices.
In addition to prosthesis, Medicare Advantage plans can also help provide coverage for procedures and services that are not covered by Original Medicare. This includes dental, vision, and hearing care. If you’d like to learn more about Medicare Advantage plans in your area, please feel free to enter your zip code into our free plan finder below! You can also give our licensed agents a call to discuss options available to you where you live.