Does Medicare Cover Rotator Cuff Surgery?

Medicare Benefits Solutions
Jun 18, 2021

If your rotator cuff sustains damage through 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 the cost of surgery?

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Do Medicare Benefits Include Rotator Cuff Surgery?

If your rotator cuff is affecting your everyday quality of life, you may require surgical intervention. However, Medicare may determine you don’t need surgery, even though the procedure may help improve your overall quality of life.

Your doctor must document that the surgery is medically necessary in order to stop any further damage to the surrounding tissue. 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. 

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 have 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.

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Rotator Cuff Problems

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 your shoulder joint.

Certain factors increase the risk of rotator cuff injury such as:

  • Certain jobs, like house painting, requiring repetitive overhead arm motions
  • Sports such as swimming, baseball, weight-lifting and tennis
  • Family history of injury
  • Age as rotator cuff tears are more common if you are 60 or older

Problems with your rotator cuff can also severely limit your range of motion. 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. 

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Rotator Cuff Surgery Costs

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.

The cost of your rotator cuff surgery will depend on your location and the setting where you have the surgery. 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.

Signs you may have a rotator cuff tear:

  • Severe pain that prevents you from sleeping on one side
  • Difficulty raising your arm
  • Shoulder pain that worsens at night
  • Cracking or popping sounds when you move your arm
  • Limited arm mobility
  • Recurrent pain, especially when it occurs with certain activities such as swimming

You won’t normally stay in the hospital after you have surgery, 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. 

TIP: Find out if your existing plan covers rotator cuff surgery.

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