Original Medicare does not provide coverage for routine vision care and services. But they do provide coverage for medically necessary eye care like glaucoma, macular degeneration, diabetes, and cataract treatments. And, specifically, what about epiretinal membrane surgery? 

Below we answer the question many seeking this treatment have which is, “does Medicare cover epiretinal membrane surgery?” In this article, we answer that question in clear, plain English. You will also find the average costs of epiretinal membrane surgery and other helpful info.

Does Medicare Cover Epiretinal Membrane Surgery?

The short answer is yes; Medicare will cover the cost of epiretinal membrane surgery. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met in order for Medicare to pay for your epiretinal membrane surgery. Below we look at what these are so you know what to expect.

Original Medicare

Original Medicare (Medicare Part A and Part B) provides coverage for epiretinal membrane surgery. Though Original Medicare usually does not provide coverage for routine eye services, they provide coverage for this procedure as it is considered medically necessary to treat epiretinal membrane. Original Medicare provides coverage for procedures that restore the function of the eye and treat chronic eye conditions such as epiretinal membrane surgery. 

Part C and Part D Coverage for Epiretinal Membrane Surgery

Medicare Advantage plans (Medicare Part C) also provide coverage for epiretinal membrane surgery. These Advantage plans have to cover all the same treatments and services that Part A & Part B cover. But they also cover things Parts A & B do not, including vision and dental services. However, exactly what they cover and what the costs are will depend on the plan you have.

Unlike Original Medicare, many Medicare Part C plans also provide coverage for routine vision care, including the purchase of eyeglasses and other vision services not covered by Original Medicare. Medicare Part C plans that include prescription drug plans will also provide coverage for medications that your healthcare provider will prescribe to you.

Medicare Part D plans provide coverage for eye medications that you need. Part D is a prescription drug plan, and just like Medicare Part C, you can get Medicare Part D plans through private insurance companies.

How Much Does Epiretinal Membrane Surgery Cost?

The costs of an epiretinal membrane surgery range from $7,700 to $14,500. Things that may affect the overall costs of your epiretinal membrane surgery include where you get the surgery, the surgeon who will do the operation and the part of the country where you live. 

What Is Epiretinal Membrane Surgery?

An epiretinal membrane surgery involves both vitrectomy and membrane peeling. An epiretinal membrane is an eye condition wherein a thin layer of scar tissue forms on the retina’s surface. The cause of an epiretinal membrane is usually aging. However, it can also be caused by various conditions such as diabetes. 

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.

Additional Info on Medicare Coverage

This article is part of our series on “What does Medicare cover?”

Also, you can check out other articles in this series including: Does Medicare cover lap band surgery?

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