Medicare’s Coverage of Heart Conditions
Cardiovascular treatments help identify, treat and manage heart and blood vessel conditions. Original Medicare (Part A and Part B) covers cardiology treatments if the patient has experienced certain conditions. Medicare Advantage (Part C) will cover everything included under Original Medicare and may offer additional benefits.
Heart Conditions Covered Under Medicare
Medicare helps cover costs associated with detecting, diagnosing and treating heart conditions. The most common heart condition covered under Medicare is coronary artery disease.
Some patients can manage their heart conditions with healthy lifestyle choices, but others may need surgeries and medications to improve. Medicare benefits are available in both situations.
Each part of Medicare provides different heart disease coverage, including benefits for diagnostic screenings, treatments and medications.
According to the Centers for Disease Control and Prevention, half of all Americans have at least one risk factor — either high blood pressure, high cholesterol or smoking — for heart disease.
- Coronary Artery Disease
- Plaque buildup damages or blocks major blood vessels, limiting blood flow to the heart
- Peripheral Artery Disease
- Blood vessels that supply blood to your limbs become blocked
- Atrial Fibrillation
- Issues with the electrical conduction system of your heart cause abnormal heart rhythms
- Heart Failure
- Issues with heart pumping/relaxing functions lead to fluid buildup and shortness of breath
If your heart disease is less common, you may be eligible for Medicare coverage if the condition is life-threatening.
Cardiovascular Disease Prevention & Screenings Covered Under Medicare
Medicare covers many preventive services and screenings for cardiovascular diseases at no cost. Your exams and lab tests are all included in your benefits.
One of the ways doctors diagnose a cardiovascular disease is through blood tests that screen for cholesterol, lipid and triglyceride levels. Part B covers cardiovascular screening blood tests every five years.
Other preventive measures include cardiovascular disease risk reduction visits or ultrasound screening for abdominal aortic aneurysm. Medicare will also pay for intensive behavioral therapy for cardiovascular disease annually.
Cardiovascular Procedures Covered Under Medicare
Cardiovascular procedures, such as open heart surgery and heart transplants, are generally considered medically necessary to protect your health and will be covered by Medicare in most cases.
Make sure your doctor, hospital or facility is enrolled in Medicare and accepting new Medicare patients before starting your treatment.
Open Heart Surgery
Medicare covers open heart surgery, even if your plan doesn’t specifically mention open heart or bypass surgery coverage. Open heart surgery is typically considered medically necessary, so Medicare will cover your treatment and rehabilitation.
Medicare Part A will cover the Medicare-approved amount for hospitalization costs, such as a semi-private room, medications and meals, once you’ve met your deductible of . You will be responsible for coinsurance costs if you are an inpatient for more than 60 days.
Medicare Part B will cover 80% of your doctor visits, tests and cardiac rehab once you’ve paid the Part B deductible.
Heart Valve Replacement
Medicare will cover Transcatheter Aortic Valve Replacement, or TAVR, when performed for an FDA-approved indication, when part of an approved clinical study or with the collection of additional clinical data.
TAVR is a procedure to treat aortic stenosis, a condition in which the aortic valve becomes narrowed and cannot properly send blood from the heart to the rest of the body. Doctors replace the diseased aortic valve with a man-made valve.
To qualify for Medicare benefits for TAVR, you must be under the care of a heart team that includes a cardiac surgeon and an interventional cardiologist. The heart team and the hospital where the team performs the procedure must meet certain criteria, such as participation in a TAVR registry.
Original Medicare will cover the majority of heart transplant costs for procedures performed at a Medicare-approved facility. If you meet certain conditions, Medicare will help pay for doctors’ services, procurement of the donor heart, immunosuppressive drugs, follow-up care, and necessary tests, labs and exams.
You will be responsible for your Part B deductible, 20% of the Medicare-approved amount for your doctor’s services and various transplant facility charges. You likely won’t owe anything to the donor or for the Medicare-certified laboratory tests.
For Medicare to cover the immunosuppressant, or transplant, drugs, it must have also covered the surgery, or an employer or union group health plan must have been required to pay before Medicare paid for the transplant. Additionally, you must have Part B when you receive the drugs, and you must have had Part A when you underwent the transplant.
Medicare's Coverage of Cardiac Rehab
Cardiac rehab is a medically supervised program. Medicare Part B will pay for cardiac rehab if you have had a specific cardiac condition or procedure, such as a heart attack in the last 12 months, a coronary artery bypass surgery, a heart valve repair or replacement, or a transplant.
The programs for cardiac rehab typically include exercise, education and counseling. There are two types of cardiac rehab: intensive and regular.
Differences Between Regular and Intensive Cardiac Rehabilitation
- Typically exercise focused
- Training sessions typically last 1 hour per day
- Slower paced, normally with one training session per day
- Equally covers exercise, nutrition education, stress management and social support
- Training sessions are fast-paced and longer than 1 hour
- Multiple training sessions available per day
- Proven to be more effective than regular cardiac rehab
Medicare's Coverage of Blood Pressure Monitors and Implantable Devices
For Medicare beneficiaries with suspected hypertension or who are at high risk of cardiac arrest, monitoring their blood pressure at home or receiving an implantable automatic defibrillator may be necessary for diagnosing and managing an ongoing health condition.
Fortunately, Medicare provides benefits to beneficiaries who need this equipment to maintain their wellbeing. Depending on your plan, provider and health status, Medicare may help pay for your equipment and any surgery needed to implant it.
At-Home Blood Pressure Monitoring
Medicare does not cover standard blood pressure monitors, commonly referred to as cuffs, except for people undergoing dialysis at home. However, it will cover ambulatory blood pressure monitoring (ABPM) for patients with suspected “white coat hypertension” and “masked hypertension.”
White coat hypertension refers to artificially high blood pressure readings, usually caused by anxiety, when a patient is in a doctor’s office. Masked hypertension is the opposite; it occurs when a patient’s blood pressure readings in a doctor’s office are lower than readings taken outside of the clinical setting.
CMS expanded coverage of ABPM in 2019 to include both indications.
ABPM allows doctors to assess patients’ blood pressure as they go about their normal daily activities versus when they’re sitting in a doctor’s office. It’s a noninvasive diagnostic test in which the patient wears a cuff on their arm and attaches a recording device to their belt or clothing.
The device tracks blood pressure over 24-hour cycles when the patient is awake and sleeping.
A licensed physician must prescribe the device and Medicare must agree that the device is medically necessary and proper for it to be covered. And the provider who supplies the device must participate in Medicare.
If you rent the device from a Medicare-certified medical equipment provider, Medicare Part B will pay 80% of the Medicare-approved amount. To avoid extra out of pocket costs, make sure the supplier is a Medicare “participating supplier.” A supplier who’s enrolled in Medicare but isn’t an officially participating supplier may charge more than the Medicare-approved amount, leaving you to pay the difference.
If you’ve been diagnosed with heart failure, you may qualify for Medicare to cover an implantable automatic defibrillator.
Medicare Part A will pay for the surgery to implant the defibrillator if you are admitted to the hospital as an inpatient. Medicare Part B will pay for the surgery if you get the device as a hospital outpatient.
If the surgery takes place in a hospital outpatient setting, you will owe the hospital a copayment. The copayment will not exceed the deductible you would have owed under Part A for an inpatient hospital stay.
You will also be responsible for 20% of the Medicare-approved cost for your doctor’s services once you have met your Part B deductible.
Implantable defibrillators are different from pacemakers, which are covered as prosthetic devices under Medicare. The device must be a reasonable and medically necessary treatment for Medicare to cover it.
Because pacemakers are categorized as durable medical equipment, Medicare Part B will cover 80% of the approved amount for the device after you’ve met your deductible.
17 Cited Research Articles
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- Centers for Medicare and Medicaid Services. (May 2012). Transcatheter Aortic Valve Replacement (TAVR). Retrieved from https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=293
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