Does Medicare Cover Prosthetic Devices?

Medicare defines prosthetic devices as a type of durable medical equipment used to replace a body part or function.

Medicare Part B covers prosthetic devices when a health care provider enrolled in Medicare orders them for you.

Artificial limbs, also called prosthesis, are the most well-known items in this category of Medicare coverage.

Medicare Part A covers surgically implanted prosthetic devices when the surgery takes place in an inpatient setting.

You must meet certain criteria for Medicare to cover your prosthetic device.

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.

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.

You’ll know early in the payment process if your item will likely meet Medicare’s coverage requirements.

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.

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.