Does Medicare Cover Shoulder Replacement Surgery?

A shoulder replacement surgery can significantly improve quality of life for individuals experiencing severe shoulder pain and disability. For many, understanding how Medicare factors into this procedure is a primary concern. Medicare provides coverage for a wide range of medical services, including shoulder replacement, which helps alleviate potential financial burdens associated with such an operation.

Medicare’s Coverage Framework for Shoulder Replacement

Original Medicare, which comprises Part A and Part B, generally covers shoulder replacement surgery when a physician certifies it as medically necessary. This coverage extends to both inpatient and outpatient settings, depending on the nature of the surgery and the patient’s condition.

Part A (Hospital Insurance) covers inpatient hospital stays. This includes costs for the operating room, nursing care, and other hospital services during an inpatient admission for shoulder replacement surgery. Part A also covers medications and therapies received during a hospital stay or in a skilled nursing facility after discharge, though limits apply to the duration of coverage.

Part B (Medical Insurance) covers services typically performed on an outpatient basis, such as arthroscopic shoulder procedures. It also covers physician services, including those from the surgeon and anesthesiologist. Part B also covers pre- and post-surgery doctor appointments, physical therapy, and durable medical equipment like arm slings or crutches, if medically necessary.

Medical Necessity and Provider Requirements

For Medicare to cover shoulder replacement surgery, medical necessity criteria must be met. The surgery must be considered reasonable and necessary for treating an illness or injury. The patient’s physician determines medical necessity and documents the specific diagnosis and justification for the procedure.

Common conditions that qualify for coverage include degenerative joint diseases like osteoarthritis, post-traumatic arthritis, rheumatoid arthritis, or rotator cuff injury. Documentation must show radiographic evidence of the diagnosis, such as irregular joint surfaces or joint space narrowing. Furthermore, there must be evidence of moderate-to-severe chronic pain or functional disability lasting at least 12 weeks. Medical records should also indicate that non-surgical treatments have been tried for at least 12 weeks and were unsuccessful, or that such conservative therapy was not appropriate.

The facility where the surgery takes place must be a Medicare-approved hospital or an ambulatory surgical center (ASC). All healthcare professionals involved in the procedure, including the surgical team, must be enrolled in and approved by Medicare.

Patient Financial Responsibilities

Even with Medicare coverage, beneficiaries are responsible for certain out-of-pocket costs. These include deductibles, coinsurance, and copayments.

For inpatient hospital stays covered by Medicare Part A, beneficiaries are responsible for a deductible of $1,676 per benefit period in 2025. A benefit period begins the day a patient is admitted as an inpatient and ends after 60 consecutive days of not receiving inpatient hospital care or skilled nursing facility care. If a hospital stay extends beyond 60 days within a benefit period, a coinsurance amount of $419 per day applies for days 61 through 90. Beyond day 90, a daily coinsurance of $838 applies for up to 60 lifetime reserve days.

For services covered by Medicare Part B, such as physician fees and outpatient therapy, an annual deductible applies. In 2025, the Part B annual deductible is $257. After meeting this deductible, beneficiaries typically pay 20% of the Medicare-approved amount for most covered services. Original Medicare does not have an annual out-of-pocket maximum.

Medicare Advantage Plans and Shoulder Replacement

Medicare Advantage (Part C) plans offer an alternative to Original Medicare and must cover at least the same services as Parts A and B, including medically necessary shoulder replacement surgery. These plans are administered by private insurance companies approved by Medicare. While basic coverage for the procedure is consistent with Original Medicare, the specific out-of-pocket costs and administrative procedures can vary significantly among plans.

Many plans also utilize a network of doctors and hospitals, requiring beneficiaries to seek care from in-network providers to receive the highest level of coverage. It is advisable to confirm with the specific Medicare Advantage plan regarding any referral requirements or prior authorization rules that might apply to the surgery.

Unlike Original Medicare, Medicare Advantage plans are required to have an annual out-of-pocket maximum. For 2025, the maximum out-of-pocket limit for in-network services in Medicare Advantage plans is $9,350, though individual plans may set lower limits. Once this limit is reached, the plan pays 100% of covered services for the remainder of the calendar year.

Prior Authorization and Appeals Process

Prior authorization may be a requirement for shoulder replacement surgery, particularly with Medicare Advantage plans or for specific circumstances under Original Medicare. The patient’s physician typically submits necessary documentation, including medical records, imaging results, and a detailed justification for the surgery, to the insurer.

Once the prior authorization request is submitted, a decision is made by the plan. If coverage for the shoulder replacement is denied, beneficiaries have the right to appeal the decision. The Medicare appeals process involves several levels, each with specific timelines and requirements.

The first level of appeal is a Redetermination, which must be filed within 120 days of receiving the denial notice. If the redetermination is unsuccessful, the next step is a Reconsideration by a Qualified Independent Contractor (QIC), which must be requested within 180 days of the redetermination decision. If the reconsideration is also denied, a hearing before an Administrative Law Judge (ALJ) can be requested within 60 days, provided the amount in controversy meets the minimum threshold of $190 in 2025. Further appeals can proceed to the Medicare Appeals Council and, ultimately, to a Judicial Review in Federal District Court, with specific monetary thresholds. Common reasons for denials include issues with medical necessity, documentation errors, or coding mistakes.