Glioblastoma multiforme is a type of brain cancer. One relatively new way to treat it is through Optune. Optune is a device that uses low-intensity electrical fields to try to prevent the spread of cancer. Most of the time Original Medicare provides coverage for cancer treatment, but does this include Optune?
If this is a treatment that you or a loved one are considering, you may have the question, “does Medicare cover Optune?” In this article, we answer that question in clear, plain English. You will also find the average costs of Optune for those who have to pay for it themselves.
Does Medicare Cover Optune?
The short answer is yes. Medicare will cover the cost of treatment using Optune. However, it won’t cover it in every situation. As you’ll usually find with Medicare, there are certain conditions that must be met in order for Medicare to pay for the treatment. Below we look at what these are for Optune so you know what to expect.
Original Medicare (Medicare Part A and Part B) provides coverage for Optune. Parts A and B provide coverage for Optune if it is considered medically necessary. The device must also be first ordered by your healthcare provider for Original Medicare to provide coverage.
For Original Medicare to provide coverage for your Optune you need to follow these requirements:
- Have histologically confirmed World Health Organization grade IV astrocytoma, newly diagnosed, supratentorial GBM
- Have received initial treatment with maximal debulking surgery (when feasible), followed by chemotherapy and radiotherapy
- Optune is only initiated within 7 weeks from the last dose of concomitant chemotherapy or radiotherapy, whichever is later
- Have no evidence of progression by Response Assessment in Neuro-Oncology (RANO) criteria
- Have a Karnofsky Performance Score (KPS) of at least 70
- The beneficiary will use Optune for an average of 18 hours per day
Although Original Medicare provides coverage for Optune, as of 2021, there is no National Coverage Determination, or NCD, for this treatment. Instead, there is a Local Coverage Determination, or LCD, for it.
In 2019, Medicare’s Durable Medical Equipment Medicare Administrative Contractors (also known as MACs) released a final LCD for the use of Optune as a treatment for glioblastoma. Supposedly, there were many restrictions that were proposed by the Centers for Medicaid and Medicare Services that are no longer in place.
All in all, Original Medicare has yet to make a National Coverage Determination for the treatment option Optune.
Part C Coverage for Optune
Medicare Advantage plans (Medicare Part C) also provide coverage for Optune. They must cover the same things that Original Medicare covers. Though these plans will also offer additional benefits and coverage that Parts A & B do not. The specifics of what Part C covers and the costs for the coverage will vary from plan to plan.
How Much Does An Optune Device Cost?
The cost of an Optune device is $21,000 on a month to month basis. This price is unlikely to vary greatly.
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 bed alarms?