Does Medicare Cover Prosthetic Devices?

Medicare Benefits Solutions
Jun 11, 2021

Medicare does provide coverage for prosthetic devices, in most cases. This coverage is supplied through Medicare Part B, the outpatient benefit. Medicare Part B provides coverage for services like doctor visits, but it also covers durable medical equipment and related medical supplies.

In order for a prosthetic device to qualify for coverage, it must be ordered by a doctor who participates in the Medicare program. Your cost will be 20% of the total amount for the device, and Medicare will cover the remaining 80%. This is the standard outpatient cost split that is used across most Part B coverage.

Does Medicare cover prosthetic devices in every state? Different states have different regulations regarding the coverage of certain types of prosthetics. For example, you may need to obtain prior authorization in order to obtain coverage for lower-limb prosthetic device coverage. To do this, you will want to work with your plan provider to ensure coverage.

Medicare and Coverage for Surgical Procedures

While some prosthetic devices can be fitted to your body without the need for surgery, others will require a surgical procedure that may require hospitalization. If you require inpatient hospitalization to receive your prosthetic device, Medicare Part A will help cover your hospital expenses.

If a device is fitted without hospitalization, Part B covers the service portion in most cases. You may find that a combination of Medicare Part A and Medicare Part B are utilized when you are faced with a situation requiring both hospitalization and the use of services offered by an outside provider.

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Medicare Coverage for Physical Therapy and Rehabilitation

Some people require physical therapy and physical rehabilitation after receiving a prosthetic device. Additionally, follow-up appointments may be necessary if a prosthetic device requires monitoring or adjusting in the future.

Medicare covers these services under Part B as long as they are medically necessary and ordered by your doctor. Physical therapy that is ordered will need to take place in a Medicare-approved setting in order to be considered for coverage. This means that your physical therapist will also need to be approved by Medicare.

Medication Coverage After Receiving a Prosthetic Device

Medicare may also cover medications that are prescribed following the introduction of a prosthetic device. This may be the case when a prosthetic is surgically implemented, but it may also be the case to treat conditions that occur as the result of prosthetic device use.

If medications are prescribed, Medicare Part D will supply coverage as long as the medications are listed in your plan’s formulary. Medications not listed in your formulary may require a waiver to receive exception status for coverage.

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