Does Medicare Cover Rotator Cuff Surgery?

Does Medicare cover rotator cuff surgery? As we age, mobility can become a challenge, especially if you suffer an injury. Your rotator cuff may not be a direct factor in helping you remain mobile, but it can impact any activities you want to do that involve range-of-motion. It can also severely limit this joint’s activity levels as it sustains damage. In turn, this can lead to issues with mobility in the future.  A drop in your overall activity level can also result in weight gain and cardiovascular issues, so maintaining your ability to move and exercise is very important.  

Medicare Benefits Solutions

Jun 18, 2021

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If your rotator cuff sustains damage through a disease or an injury, it can lead to severe pain. It could also potentially damage any surrounding tissue because your body may try to compensate for the fact that you lost your range-of-motion. When the damage gets too bad, rotator cuff surgery may be the most viable option. Will your Medicare benefits cover rotator cuff surgery?

Do Medicare benefits extend to rotator cuff surgery?

When it comes to Medicare insurance, some people can have rotator cuff surgery and use their Medicare to cover most of the cost if it’s medically necessary. Any outpatient surgical procedures like this surgery use Medicare Part B for coverage. If you need to be formally admitted into the hospital for the surgery, Medicare Part A may cover the costs of your surgery. However, the surgery and the treatment that follows has to be part of an approved plan to prevent a disease or heal. Follow-up after the surgery may also be covered by Part B. 

If your rotator cuff is impacting is your range-of-motion, Medicare may deem a surgical procedure not medically necessary, even though it may help improve your overall quality of life. Your doctor may demonstrate that the surgery is medically necessary in order to stop any further damage to the surrounding tissue. Medicare will require documentation of this. Medicare is more likely to approve the surgery if it’s part of a comprehensive treatment plan to prevent a disease from spreading, like cancer. 

If you require a short stay in a skilled nursing facility for therapy following your surgery, Medicare Part A could help cover the costs. These types of facilities also give you more care when you stay there, and Part A will be the benefit to cover the costs. If you need care or supplies after you have your rotator cuff surgery after the skilled nursing facility releases you, Part B could kick back in. 

Rotator cuff surgery costs

The cost of your rotator cuff surgery will depend on your location and the setting that you have the surgery in. For example, having the surgery in an ambulatory clinic as an outpatient can cost around $2,800 before insurance. If you have the surgery in an inpatient hospital, you will pay more. The average cost is $6,000 before insurance. 

As long as it’s medically necessary, Medicare will pay 20% of the Medicare-approved amount as long as your provider accepts assignment and you have the procedure performed in a Medicare-approved facility. For the ambulatory surgical center, you’d pay $560 on average after Medicare. For the inpatient hospital, you’d pay $1,200 after Medicare pays.

If you are enrolled in a Medicare Advantage plan, you will have at least the same benefits as Original Medicare Part A and Part B, but many MA plans include additional coverage. Check with your plan directly to find out your benefits in relation to rotator cuff surgery.

Rotator cuff surgery explained

Having surgery to repair your rotator cuff for disorders or an injury can quickly solve a host of problems. The surgery is also minimally-invasive because it uses arthroscopic techniques and technology from start to finish. During the surgery, the surgeon works to reattach tissues and tendons to your shoulder bone. You could have torn these tendons or tissues loose when you injured yourself, or exertion can cause them to come loose too. Certain diseases can also cause the connective tissue to deteriorate and come loose. 

Usually, this is an outpatient surgical procedure. You won’t normally stay in the hospital after you have it, and your overall health and age will play a direct role in the recovery process. You’ll also have to use a tiered method to help you slowly regain your total range-of-motion. Recovery from this surgery usually involves targeted exercises and physical therapy. 

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