Does Medicare Cover Prosthetic Devices?
Original Medicare typically pays 80 percent of all approved costs for prosthetic devices, including artificial eyes and limbs. Your prosthetic device must be considered medically necessary to receive Medicare coverage. You may need to get prior authorization before Medicare pays your claim.
Medicare Coverage of Prosthetic Devices
Medicare defines prosthetic devices as a type of durable medical equipment used to replace a body part or function.
Artificial limbs, also called prosthesis, are the most well-known items in this category of Medicare coverage.
- Artificial limbs, including arms, legs and feet
- Prosthetic shoes (when all or a substantial portion of the front part of the foot is missing)
- Breast prostheses (including a surgical bra)
- One pair of conventional eyeglasses or contact lenses provided after cataract surgery
- Ostomy bags and certain related supplies
- Some surgically implanted prosthetic devices, including cochlear implants for hearing loss
- Artificial eyes
- Urological supplies
You must meet certain criteria for Medicare to cover your prosthetic device.
- Medically necessary
- Not purely cosmetic in nature
- Ordered by a physician who participates in Medicare
- Ordered and obtained from a supplier that participates in Medicare
If you need a replacement prosthetic device, your physician must document what is wrong with your current prosthesis and how it limits your daily function.
Typically, for Medicare to cover a replacement prosthetic device, the cost to repair your device must be more than 60 percent of the cost for a new device.
What Medicare Doesn’t Cover
Medicare will not cover a prosthetic device if it is not considered medically necessary. Several prosthetics and implants are considered cosmetic, so they are not covered by Medicare.
- Cosmetic breast implants
- Wigs or head coverings for hair loss
You’ll know early in the payment process if your item will likely meet Medicare’s coverage requirements.
Prior Authorization and Medicare-Approved Suppliers
You must go to a durable medical equipment supplier that’s enrolled in Medicare or Medicare won’t pay for your device.
If you’re enrolled in a Medicare Advantage plan, you may be restricted to certain suppliers within your coverage network. Contact your plan provider before renting or ordering prosthetics.
Keep in mind that Medicare may require you to get prior authorization for your device before it will pay the claim.
For example, in February 2020, the U.S. Centers for Medicare & Medicaid Services announced that six lower limb prosthetic codes will now require Medicare prior authorization as a condition of payment.
A prior authorization request is submitted by the provider or supplier on your behalf to Medicare.
Prior authorization helps Medicare ensure that all applicable coverage, payment and coding rules are met before you receive your device.
How Much Will My Prosthetic Device Cost with Medicare?
Medicare Part B covers 80 percent of approved costs for external prosthetic devices.
You will pay 20 percent, and the Part B deductible applies. You may owe less if you have any secondary insurance, such as Medicaid.
If your prosthesis needs to be surgically implanted, Medicare Part A will cover the inpatient procedure.
In this case, you will need to meet your Part A deductible. Beyond that, there are no copayments for your first 60 days in the hospital.
If you require a stay in a skilled nursing facility or rehabilitation center following your surgery, Part A will cover your stay.
You will pay nothing for your first 20 days in a skilled nursing facility. For days 21 to 100, you will owe a copayment for each day.
After 100 days in a skilled nursing facility, you are responsible for all costs.
7 Cited Research Articles
- U.S. National Library of Medicine. (2020, December 22). Artificial Limbs. Retrieved from https://medlineplus.gov/artificiallimbs.html
- United Healthcare. (2020, June 16). Coverage Summary: Durable Medical Equipment, Prosthetics, Corrective Appliances/Orthotics and Medical Supplies. Retrieved from https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/dme-prosthetics-corrective-appliances-orthotics-med-supplies.pdf
- U.S. Centers for Medicare & Medicaid Services. (2020). Prior Authorization Process for Lower Limb Prosthetics (LLPs). Retrieved from https://www.cms.gov/files/document/open-door-forum-slides-llps-03-11-2020.pdf
- American Orthotic & Prosthetic Association. (2020, February 11). CMS Announces Medicare Prior Authorization for 6 Lower Limb Prosthetic Codes. Retrieved from https://www.aopanet.org/2020/02/cms-announces-medicare-prior-authorization-for-6-lower-limb-prosthetic-codes/
- U.S. Centers for Medicare & Medicaid Services. (n.d.). National Coverage Determination (NCD) for Prosthetic Shoe (280.10). Retrieved from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=208&ncdver=1&bc=BAAAEAAAAAAA
- Medicare.gov. (n.d.). Artificial eyes & limbs. Retrieved from https://www.medicare.gov/coverage/artificial-eyes-limbs
- Medicare.gov. (n.d.). Prosthetic devices. Retrieved from https://www.medicare.gov/coverage/prosthetic-devices