Medicare covers rotator cuff surgery when it’s deemed medically necessary by a qualified healthcare provider.
Your rotator cuff is the group of muscles and tendons that hold your shoulder joint in place and allow you to move your arm and shoulder. If the rotator cuff becomes damaged or injured in some way, you can have pain, weakness, and reduced range of motion, which can snowball into mobility and other health issues.
Rotator cuff injuries are typically caused by progressive wear and tear of the tissue over time, including prolonged heavy lifting, though a single fall or accident can also cause damage. If the injury interferes with your daily life, hasn’t improved over several months’ time, or you have actual damage like a tear, you may need surgery. If this is the case, it’s important to understand if rotator cuff surgery is covered by Medicare, as well as other options you may have.
Medicare coverage for rotator cuff surgery
If rotator cuff surgery is deemed medically necessary by your provider, it will likely be covered by Medicare. These surgeries are typically an outpatient procedure, so Medicare Part B (medical insurance) would cover:
· The procedure
· Additional follow-up visits with your provider
· Any supplies you may need after returning home
· Physical therapy after the surgery
If you require a temporary stay in a skilled nursing facility (SNF), that would be covered by Medicare Part A (hospital insurance). This coverage would include any additional care or services you receive while there. However, Medicare only covers care received in an SNF if it follows a qualifying three-day hospital stay.
Do I need a referral to see an orthopedic surgeon?
If you have a rotator cuff injury or suspect a tear, you’ll likely need to see an orthopedic surgeon. Original Medicare doesn’t require referrals to see a specialist, so you can make an appointment to see an orthopedic doctor if you have concerns. However, it’s still important to ensure the doctor you choose accepts assignment, meaning they agree to accept the Medicare-approved amount for services. You can do that here.
While many tests, items, and services are covered by either Part A or Part B, your doctor can help you understand if Medicare will cover what you need. You can also use the free online search tool on Medicare.gov to learn if a test, item, or service is covered and how much it would cost you. Anything you receive that is not covered by Medicare must be paid for out-of-pocket.
If you have a Medicare Advantage (Part C) plan, you will likely need a referral to see a specialist, though this depends on what type of plan you have. For example, HMO plans require referrals from your primary care physician (PCP) while PPO plans do not. Keep in mind you’ll still want to check that a service will be covered, especially if you have a PPO plan. Check your plan’s Evidence of Coverage (EOC) or contact the plan directly to learn more.
How much does rotator cuff surgery cost?
According to Medicare.gov, the average cost for rotator cuff surgery is:
· $818 for surgery at an ambulatory surgical center (including facility and provider fees)
· $1,498 for surgery at a hospital outpatient department (including facility and provider fees)
However, keep in mind these costs can vary depending on:
· Whether you’ve met the Part B deductible
· Where you get the surgery (you usually pay more out-of-pocket as a hospital outpatient)
· How extensive your injury is
· Whether there are any surgical complications
· Care and services you need after the surgery
There are also other factors that can impact the cost, so talk with your doctor about what you can expect.
If you have a Medicare supplement plan (Medigap), it may help pay for services covered by Original Medicare including:
Having a Medigap plan can help save you money on your surgery and services/supplies needed afterward. Keep in mind that if you receive any services, care, or supplies not covered by Original Medicare Part A or Part B, they will also not be covered by Medigap, and you’ll have to pay those costs out-of-pocket.
If you have a Part C plan, your costs may differ. Check with your plan to learn more about the out-of-pocket expenses you may be responsible for.
Compare your Medicare plan options with our Find a Plan tool. It’s fast and easy to use. Just enter your zip code to start reviewing Medicare plans in your area.
How do I know if I need rotator cuff surgery?
Rotator cuff tears often feel like a dull ache deep in the shoulder, especially when doing specific movements such as lifting or lowering the arm. You may not be able to sleep due to pain or discomfort when lying on the injured shoulder. Other than shoulder pain, additional symptoms may include:
· Grating or cracking sounds when you move your arm
· Limited ability to move your arm
· Muscle weakness
You should call your doctor if your pain worsens or interferes with your daily activities or ability to sleep, or you have difficulty using your shoulder or arm.
After a physical exam, your provider may order additional tests to determine the extent of your shoulder injury, including an X-ray and/or MRI. (This diagnostic imaging would be covered by Medicare Part B).
Rotator cuff injuries may be partial or full tears, or simply irritated muscles or tendons, so your provider must determine the level of severity to understand if you need surgery or not. Note there are also different types of surgical procedures for a rotator cuff repair, including:
· Arthroscopic surgery, which is when a small camera is inserted through a small incision in your shoulder and your surgeon uses those images to guide miniature surgical instruments in the shoulder, repairing the injury
· Open surgery, which is when an incision is made and a large muscle is moved out of the way to do the surgery, typically only done for large or more complex tears
Your doctor may also recommend a combination of arthroscopy or open surgery, but they will determine which type of surgery is best to restore the function and flexibility of the shoulder as well as relieve your pain. They will also take into account recovery time and other factors that may be important to the decision.
Non-surgical options for a rotator cuff injury
Surgery is not the only option for a rotator cuff injury. Other treatments include:
· Nonsteroidal anti-inflammatory medications
· Strengthening and stretching exercises
· Ultrasound therapy
· Corticosteroid injections
Depending on the severity of your injury and other health factors, your doctor will determine the best treatment option for you.
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