Does Medicare Cover Rotator Cuff Surgery?
- Learn about Medicare coverage for rotator cuff surgery to make an informed decision about care. Find out the average cost and how much you might have to pay.
The rotator cuff is the name for the muscles and tendons around your shoulder joint that help your arm move in the socket. Accidents and years of overhead activities or heavy lifting can cause the rotator cuff to become damaged. A study published in the Journal of Orthopaedics estimates that roughly 22% of Americans have some type of rotator cuff injury. If you're one of the millions impacted by pain and restricted movement due to the condition, your doctor may recommend surgery for treatment, and often, Medicare will help cover the costs of the procedure.
Does Medicare Cover Rotator Cuff Surgery?
Generally, Medicare provides coverage for rotator cuff surgery when it's medically necessary. Unfortunately, Medicare doesn't consider all injuries to be eligible for treatment. Even if Medicare does cover the procedure, you'll likely be responsible for paying a portion of the costs.
When Does Medicare Cover Rotator Cuff Surgery?
Typically, for rotator cuff surgery to fit the definition of medically necessary, your doctor must state that the procedure is needed to prevent further damage to other tissues in the shoulder. Pain and limited range of motion alone aren't usually enough to satisfy Medicare's requirements. You may also need to try other interventions such as physical therapy, ice and corticosteroid injections before Medicare will cover your surgery.
What Does Medicare Part A Cover for Rotator Cuff Surgery?
Medicare Part A covers hospitalization expenses. If your rotator cuff surgery is medically necessary, this portion of Medicare will usually pay for your room and board if you need to be admitted to an approved hospital for surgery. In addition, Medicare Part A may pay for a temporary stay in a rehabilitation center if you need therapy following a covered surgery. You'll usually need to satisfy a deductible before coverage begins, and if your stay is lengthy, you're likely to be assessed coinsurance fees.
What Does Medicare Part B Cover for Rotator Cuff Surgery?
Medicare Part B generally covers the cost of the actual procedure performed on the rotator cuff. In addition, this part of Medicare Part B usually pays for doctor's consultation visits and any imaging tests, such as X-rays and MRIs, that must be performed prior to surgery. You'll likely need to meet your deductible before coverage begins. In addition, you normally must pay 20% of the costs under Medicare Part B coverage. For example, if the surgery costs $1,000, Medicare would pay 80% or $800, and you would need to pay the remaining 20% or $200.
What Does Medicare Part D Cover for Rotator Cuff Surgery?
Medicare Part D would likely pay for medications that your doctor prescribes following surgery, such as painkillers for lessening discomfort and antibiotics for reducing the risk of infection. How much you'll have to pay for any medications depends on the plan's formulary, its listing of which drugs are covered. Formularies classify drugs into various tiers based on cost and whether they are name brand or generic. Copayments are usually less for drugs on lower tiers.
Your out-of-pocket expenses for any medications prescribed after rotator cuff surgery also vary based on your stage of coverage as follows:
- Deductible stage. Before you pay your deductible, you typically must cover the full cost of medications.
- Post-deductible stage. Once you have satisfied your plan's deductible, you'll usually only pay a copay or coinsurance.
- Donut hole stage. When your total drug spending exceeds a preset limit, you enter the donut hole stage and generally must pay 25% of the cost of medications.
- Post-donut hole stage. If your total drug spending reaches the level for catastrophic coverage, your health plan will likely begin paying for most of your drugs, leaving you responsible only for a copay or coinsurance.
Do Medicare Advantage Plans Pay for Rotator Cuff Surgery?
Medicare Advantage Plans must usually pay for at least as much as Medicare Parts A and B do. As a result, if your rotator cuff surgery is deemed medically necessary, your plan is likely to pay for it. Plans that include prescription drug coverage may also help pay for any medications your doctor recommends after the procedure. Depending on your plan, you may have to:
- Satisfy a deductible
- Pay copays or coinsurance
- Choose a doctor, hospital or outpatient surgical center in your plan's network
How Much Does Rotator Cuff Surgery Cost with Medicare?
As of October 2021, Medicare.gov estimates that the average cost for rotator cuff surgery at an ambulatory surgical center is around $4,000. Medicare plans typically pay for a little over $3,000 of that average cost, with a remaining $800 or so left as out-of-pocket expenses. Procedures performed in hospital outpatient departments average around $7,300 with Medicare paying a little less than $6,000, leaving a remainder of about $1,500 that is considered out-of-pocket expense. The actual price you'll pay for rotator cuff surgery depends on where you live, what type of procedure is performed, how many doctors are involved in the surgery and other factors.