Medicare covers shoulder replacement surgery, but only if your doctor documents that you have severe arthritis or a rotator cuff tear that has not improved with nonsurgical treatment

Medicare Part B pays for shoulder replacement when the surgery is deemed medically necessary. This means your surgeon must show that you have tried physical therapy, anti-inflammatory medication, or steroid injections first, and that those treatments did not relieve your pain enough to restore function. Medicare will not pay for the surgery if your condition could still improve with conservative care.

The coverage includes the surgeon's fee, the facility cost, anesthesia, and the implant itself. You pay 20 percent of the approved amount after you meet your Part B deductible for the year. If you have a Medigap or Medicare Advantage plan, your out-of-pocket cost may be lower, depending on your plan's terms.

Key Takeaways

  • Medicare Part B covers shoulder replacement surgery when your doctor documents that you have severe arthritis or a rotator cuff tear and that nonsurgical treatment has failed.
  • You must meet your Part B deductible before Medicare begins to pay, and you will owe 20 percent of the approved surgical cost after that.
  • Your surgeon's office must obtain prior authorization from Medicare before the surgery, or the claim may be denied.
  • If you have a Medigap plan, it typically covers the 20 percent coinsurance; if you have Medicare Advantage, your cost depends on your plan's network and deductible.

What Medicare requires before approving shoulder replacement

Medicare requires your doctor to document a specific diagnosis and a clear record of failed conservative treatment. The most common diagnoses that Medicare covers are severe osteoarthritis of the shoulder joint, rheumatoid arthritis, or a massive rotator cuff tear that cannot be repaired with arthroscopic surgery.

Your medical record must show that you tried at least one of the following: physical therapy for at least 4 to 12 weeks, oral anti-inflammatory medication, or steroid injections into the shoulder joint. Some surgeons also document failed arthroscopic repair before moving to open replacement. Medicare reviewers look at the dates of these treatments and the notes from your doctor explaining why they did not work for you.

Your surgeon's office will submit a request for prior authorization to Medicare before scheduling the surgery. This request includes your imaging (X-rays or MRI), your medical history, and documentation of the treatments you have already tried. Medicare typically responds within 5 to 10 business days. If Medicare denies the request, your surgeon can appeal with additional medical records.

How much you will pay out of pocket

Your out-of-pocket cost depends on whether you have met your Part B deductible for the calendar year. For 2024, the Part B deductible is $240. Once you meet that deductible, Medicare pays 80 percent of the approved surgical cost, and you pay 20 percent.

The approved amount varies by region and facility. A shoulder replacement surgery typically has an approved amount between $15,000 and $25,000, meaning your 20 percent coinsurance could range from $3,000 to $5,000. This does not include the cost of any imaging, blood work, or office visits before or after surgery, which have their own deductible and coinsurance rules.

If you have Original Medicare only and no supplemental coverage, you are responsible for the full 20 percent. If you have a Medigap plan (also called Medigap insurance), it typically covers this coinsurance, though you should check your specific plan documents. If you have Medicare Advantage, your cost depends on whether the surgeon and facility are in your plan's network and whether you have met your plan's deductible.

Medicare Advantage plans and shoulder replacement

Medicare Advantage plans must cover shoulder replacement surgery under the same medical necessity rules as Original Medicare, but your out-of-pocket cost and approval process may differ. Some Advantage plans require you to use an in-network surgeon; if you see an out-of-network surgeon, you may owe more or the plan may not cover the surgery at all.

Many Medicare Advantage plans have a separate deductible for surgery, which can range from $0 to $500 or more. After you meet that deductible, you typically owe a copay or coinsurance for the facility and surgeon. Some plans cap your total out-of-pocket costs for the year; once you reach that cap, the plan pays 100 percent of covered services for the rest of the year.

Before scheduling surgery, call your Medicare Advantage plan and ask whether your surgeon and the surgical facility are in network, what your deductible is, and what your coinsurance or copay will be. Your surgeon's office can also contact the plan to verify coverage and get a pre-authorization number.

What happens if Medicare denies your request

If Medicare denies prior authorization, your surgeon can file an appeal. The appeal process begins with a reconsideration, where a different Medicare reviewer looks at your case. Your surgeon's office will submit additional medical records, imaging, or a letter from your doctor explaining why surgery is necessary for you.

A reconsideration typically takes 30 days. If Medicare denies the reconsideration, you can request a hearing before an administrative law judge, though this process can take several months. During the appeal, you can choose to have the surgery and pay out of pocket, understanding that you may not be reimbursed if the appeal is ultimately denied.

The most common reason for denial is insufficient documentation of conservative treatment. If your appeal is denied, ask your surgeon whether a different surgical approach (such as arthroscopic repair instead of replacement) might be covered, or whether waiting longer and trying additional physical therapy would strengthen your case for future approval.

Preparing for surgery and post-operative care

Once Medicare approves your surgery, your surgeon's office will schedule the procedure and send you pre-operative instructions. You will need lab work and possibly an EKG or chest X-ray before surgery; these tests are covered under Medicare Part B with the same deductible and coinsurance rules.

After surgery, Medicare covers physical therapy, office visits, and imaging related to your recovery. Inpatient rehabilitation (if you need it) is covered under Medicare Part A if you are admitted to the hospital for at least three days before transfer to a rehabilitation facility. Outpatient physical therapy is covered under Part B, though you will owe coinsurance for each visit after you meet your deductible.

Keep all receipts and explanation of benefits statements from Medicare. If you receive a bill from your surgeon or facility after Medicare has paid, compare it to the explanation of benefits to make sure you are not being overcharged. If you see a charge you do not recognize, contact the facility's billing department or call Medicare at 1-800-MEDICARE.

Frequently Asked Questions

Do I need to try physical therapy before Medicare will cover shoulder replacement?

Yes. Medicare requires documentation that you tried nonsurgical treatment first, usually physical therapy for several weeks. Your medical record must show the dates you attended therapy and notes from your therapist or doctor explaining why it did not relieve your pain enough to restore function.

Will Medicare cover a second shoulder replacement on the other shoulder?

Yes, if the second shoulder meets the same medical necessity criteria. You will need prior authorization for the second surgery just as you did for the first. However, if both surgeries happen in the same calendar year, you only pay the Part B deductible once.

What if my surgeon is not accepting Medicare patients?

You will need to find a surgeon who accepts Medicare assignment. You can search for surgeons in your area through the Medicare provider search tool on Medicare.gov, or ask your primary care doctor for a referral to a Medicare-accepting orthopedic surgeon. If you see a non-participating surgeon, you may owe more out of pocket.

Does Medicare cover the cost of a shoulder immobilizer or other equipment after surgery?

Medicare covers durable medical equipment like a sling or shoulder immobilizer if your doctor prescribes it and it is medically necessary. You will owe 20 percent coinsurance after your Part B deductible. Some equipment may require prior authorization; your surgeon's office can request this before you pick up the equipment.

Can I have shoulder replacement surgery at an outpatient surgery center instead of a hospital?

Yes. Medicare covers shoulder replacement at an outpatient surgery center if the facility is Medicare-certified. Your out-of-pocket cost may be slightly lower at an outpatient center than at a hospital, but you will still owe the same 20 percent coinsurance after your deductible. Ask your surgeon whether the facility where they plan to perform your surgery is Medicare-certified.