As we get older, our bodies become frailer, increasing the risk of suffering from medical conditions and severe injuries such as fractures. Bone fractures can cause chronic pain and immobility.
Fractures are commonly caused by conditions such as osteoporosis. One well-known treatment option that can help people is kyphoplasty. If this is a treatment you or a loved one want to try, a common question you likely have is, “Does Medicare cover Kyphoplasty?”
In this article, we answer the question in clear, plain English. You will also find the average costs of kyphoplasty if you have to pay for it out of pocket.
Does Medicare Cover Kyphoplasty?
The short answer is yes; Medicare will cover the cost of kyphoplasty. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met for Medicare to pay.
Below we look at what these are so you know what to expect. But, first, let’s explore what kyphoplasty is in the first place.
What Is Kyphoplasty?
Kyphoplasty is a type of vertebral augmentation that involves using bone cement to stabilize and restore the structure of fractured vertebrae.
To inject the cement, the surgeon inserts a balloon into the appropriate area, which is then inflated to lift the broken vertebra and create a cavity for the bone cement to fit inside.
Before the procedure, patients are given mild sedation and local anesthetics. However, the treatment can be performed with only local anesthesia if the patient cannot tolerate sedatives or has other medical needs that preclude their use.
Original Medicare Coverage of Kyphoplasty
Original Medicare (Medicare Part A and Part B) provides coverage for kyphoplasty. This plan provides coverage for kyphoplasty if it is considered medically necessary. Your healthcare provider must first order this treatment for Original Medicare to provide coverage.
When is Kyphoplasty Covered by Plan B?
Coverage for kyphoplasty is provided by Medicare Part B if it takes place in an outpatient setting. Part B provides kyphoplasty coverage if deemed medically necessary by your healthcare provider.
However, your healthcare provider may first advise other types of treatments before seeing kyphoplasty as a treatment option. These may include prescription medications to help delay bone loss or medical equipment and devices such as back braces, which may help relieve pressure along the spine.
More on Plan B Coverage and Costs
Medicare Part B may require prior authorization and extensive documentation for them to provide coverage for your kyphoplasty. There may also be restrictions on which specialists and outpatient facilities can perform kyphoplasty.
You may also need proof of a follow-up treatment plan from your healthcare provider for Medicare Part B to provide coverage.
Once approved, Medicare Part B covers 80 percent of the costs of kyphoplasty. You will pay for the remaining 20 percent.
Medicare Advantage Coverage of Kyphoplasty
Medicare Advantage plans (Medicare Part C) also provide coverage for kyphoplasty. Part C plans must cover anything that Original Medicare covers.
Part C plans also cover some treatments, services, and equipment that Original Medicare does not. Precisely what it covers and how much the out-of-pocket costs vary depending on your plan’s specifics.
How Much Does Kyphoplasty Cost?
The national average cost of kyphoplasty is right around $21,000. However, some offer less expensive rates where you can find this type of treatment for a little under $11,000.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always 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 Orencia?