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Wondering does Medicare cover prolapse surgery? Good news—it generally does! There’s more to the story, though. As with other medical issues, you must check certain boxes for Medicare to pay. Stay with us while we explain how to protect yourself.
Do you worry about how you can afford prolapse surgery? You’re not alone. Medicare helps many pay their medical bills and get the care they need. Our guide will help you determine if Medicare will cover your surgery so you can focus on feeling better rather than worrying about money.
Below, you’ll learn:
- What you need to do to make sure Medicare covers your prolapse surgery.
- How “Original Medicare” is different from “Medicare Advantage” when it comes to this surgery.
- The paperwork and doctor visits you’ll need before surgery.
- Tips to handle those extra costs, like co-pays and deductibles, that might pop up.
Consider this your guide to figuring out how to get prolapse surgery paid for by Medicare. Let’s get started!
Table of Contents
Does Medicare Cover Prolapse Surgery?
The short answer is yes; Medicare will cover the cost of prolapse surgery. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met for Medicare to pay for your prolapse surgery. Below we look at what these are so you know what to expect.
Original Medicare (Medicare Part A and Part B) provides coverage for prolapse surgery. This plan provides coverage for your prolapse surgery if it is considered medically necessary.
Your healthcare provider must first order the operation for Original Medicare to provide coverage. Coverage for prolapse surgery is provided by Medicare Part A if it takes place in an inpatient setting.
Part A will cover 100% of the costs of hospital stays for up to 60 days. For days 61 to 90, Medicare Part A will still provide coverage. However, you will pay a copay each day you are still in the hospital.
On the other hand, coverage for prolapse surgery is provided by Medicare Part B when it takes place in an outpatient setting. Once approved, Medicare Part B covers 80% of the costs of prolapse surgery. You will pay for the remaining 20%.
Part C (Medicare Advantage) Coverage for Prolapse Surgery
Medicare Advantage plans (Medicare Part C) also provide coverage for prolapse surgery. They cover everything Original Medicare covers and offer some additional benefits as well.
Each plan is different though, so the additional benefits a plan offers and the costs will depend on the plan you have. Medicare Part C plans that include prescription drug plans will also provide coverage for medications your healthcare provider will prescribe to you.
Medicare Part D plans provide coverage for medications you need after prolapse surgery. Part D is a prescription drug plan. Private insurance companies offer Medicare Part D plans, just like Medicare Part C does.
Navigating Medicare Coverage for Prolapse Therapy
If you need prolapse therapy and rely on Medicare, here’s a guide on how to go through the process of getting coverage:
Flowchart for Medicare Process for Prolapse Therapy
Visit Primary Care Physician
Get Referral for Specialist
Understand Medicare Part B Coverage
Explore MSPs, Medicaid, SHIPs, Patient Assistance Programs, Medigap
Keep Records, Ask Questions
- Consultation First: Begin by visiting your primary care physician to talk about your symptoms. If they think you might have a prolapse, they might recommend seeing a specialist like a gynecologist, urologist, or colorectal surgeon.
- Get the Paperwork Right: To see a specialist through Medicare, you’ll need a referral from your primary doctor. They’ll document your symptoms and explain why you need the specialist’s help.
- Know the Costs: While Medicare Part B can cover some expenses related to prolapse therapy, you might still need to pay co-pays, deductibles, and possibly other fees.
If money’s tight, several programs might help:
- Medicare Savings Programs (MSPs): These can reduce Medicare-related costs for those with limited income.
- Medicaid: Depending on where you live, Medicaid might cover prolapse therapy costs.
- State Health Insurance Programs (SHIPs): SHIPs give free advice on understanding Medicare and other insurance choices.
- Patient Assistance Programs: Drug companies sometimes have these to help with medication costs.
Lastly, consider Medigap: It’s a private insurance that can assist with extra Medicare charges like co-pays and deductibles. Multiple plans are available, so choose the one fitting your needs and budget.
|What it Covers
|Medicare Savings Programs
|Reduced Medicare-related costs
|Prolapse therapy costs
|Varies by state
|State Health Insurance Programs
|Free advice on Medicare
|Open to all
|Patient Assistance Programs
|Varies by program
|Extra Medicare charges like co-pays and deductibles
|Varies by plan
A few more tips: Always get written records about your health situation, treatment options, and expected costs. Never hesitate to ask medical professionals about your coverage.
If you encounter issues with your Medicare benefits, remain persistent and reach out to your Medicare provider or the Centers for Medicare & Medicaid Services for help.
How Much Does Prolapse Surgery Cost?
The average cost of prolapse surgery ranges from $6,000 to $9,000. The exact cost depends on the specific surgery being performed.
Understanding Prolapse: Causes, Types, and Symptoms
What Is Prolapse and Where Does It Happen?
Prolapse is when an organ or tissue moves out of its usual place. It can happen anywhere in the body but is most often seen in the pelvic area.
In the pelvis, organs like the uterus, bladder, or rectum can sag or slip because the muscles and ligaments holding them up get weak or damaged. The most usual kind is uterine prolapse, where the uterus falls into the vagina.
But other kinds, like when the bladder or rectum sags into the vagina, can happen too. There are also other kinds of prolapse in different body parts, like the rectum, heart valve, and spinal cord.
How Often Does Prolapse Happen?
Prolapse in the pelvic area is quite common, especially among women. About half of all women may face some form of pelvic prolapse by the time they are 80.
The risk goes up as you get older and other things can increase your risk, like having a baby through vaginal delivery, being overweight, having frequent constipation, lifting heavy things, smoking, and going through menopause.
What Are the Signs and Possible Problems?
The signs of prolapse can change depending on how severe it is.
Some common signs are feeling full or pressure in your pelvis, seeing a bulge in your vagina, feeling pain in your pelvis, back, or belly, having trouble going to the bathroom, leaking pee or poop, or feeling pain during sex.
Sometimes prolapse can lead to bigger problems like urinary infections, fecal impaction, loss of bladder or bowel control, sexual dysfunction, or even nerve damage. If you have any of these symptoms, it’s a good idea to talk to a doctor.
Treatments for Prolapse
There are two primary treatments for prolapse: non-surgical and surgical.
These exercises help strengthen the supporting muscles of the pelvic organs. Specialists in pelvic floor therapy can guide you through these exercises and create a plan tailored for you.
A pessary is a device placed in the vagina to support the pelvic organs. There are various pessary shapes and sizes, and a doctor can assist you in choosing the right one.
The best surgical approach depends on your prolapse’s severity, your age, and overall health. Common surgeries include:
- Anterior repair: Fixes a bladder prolapse, known as a cystocele.
- Posterior repair: Addresses a rectal prolapse, termed a rectocele.
- Sacrocolpopexy: Lifts and secures the prolapsed organs to the sacrum, a bone at the spine’s base.
- Vaginal hysterectomy: Involves removing the uterus.
Recovery After Surgery
Recovery durations vary based on the surgery performed. Typically, a hospital stay of one to two days post-surgery is expected. It’s essential to rest for several weeks post-operation, and you might experience mild pain and some bleeding.
In short, this piece answered the most important question: Does Medicare cover prolapse surgery? We went into detail about the conditions that must be met for Medicare to cover this procedure.
We also talked about the changes between Original Medicare and Medicare Advantage plans. Understanding these details can help you a lot on your way to better health. It can help you make better decisions about your treatment choices and your finances.
If you found this guide useful, consider sharing it with others who are navigating the complexities of Medicare and prolapse surgery coverage. This topic is essential for those who may face this medical condition and are unsure about the financial aspects.
Frequently Asked Questions
How Much Does Fixing a Prolapse Cost?
Will Medicare Cover Surgery in the Case of a Prolapsed Uterus?
Most insurance plans, including Medicare, will usually cover it. If you’re on Medicare and your doctor says you need a hysterectomy, Medicare will help pay for it.
You can get this help whether you’re on Original Medicare or Medicare Advantage. You might still have to pay some costs yourself, like a deductible.
During What Stage of a Prolapse Do You Need Surgery?
Surgery is recommended for stage three or four prolapse or uterine removal. Younger women with prolapsed uteruses who don’t want them removed can have this treatment.
Surgery may not be advised for stage one or two prolapse. Pelvic floor muscle strengthening exercises can work if done correctly and consistently.
What Kind of Surgery Is the Most Effective for Prolapse?
The most effective surgery for prolapse depends on the type of prolapse, the severity of the prolapse, and the patient’s individual circumstances. Some of the most common surgeries for prolapse include vaginal repair surgery, sacrocolpopexy, and hysterectomy.
What Can Happen if You Don’t Repair a Prolapse?
The lining of a lowered uterus might rub against your clothes if untreated. Cuts, sores, and infections might result.
If it doesn’t affect you, a lowered uterus may not worsen or require treatment. Simple therapies can relieve mild discomfort and prevent uterine removal to preserve fertility.
Can a Prolapse Be Reversed Without Surgery?
Surgery may not be needed for minor prolapses. Sometimes organs heal themselves or don’t worsen. Many people feel better with pelvic floor exercises or vaginal devices.
This pessary is often the first choice for mild to moderate prolapse. It supports fallen organs in the vagina with rubber or silicone.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. 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?”