Does Medicare Cover Axonics Therapy

When it comes to Medicare coverage, figuring out what’s covered and what’s not can feel like trying to untangle a knotted-up garden hose—it can get pretty twisted. One question I hear a lot as a Medicare Advisor at Medicare Advisors Insurance Group LLC is whether Medicare covers Axonics Therapy. Axonics Therapy is a relatively new treatment for urinary and fecal incontinence that involves implanting a device that sends gentle pulses to the sacral nerves to help control bladder and bowel movements. It sounds promising but does it fall under Medicare’s coverage?

What is Axonics Therapy

Axonics Therapy is a long-term solution for people who struggle with urinary and fecal incontinence. The therapy involves a small device implanted in the lower back that stimulates the nerves responsible for bladder and bowel control. This tiny device acts like a pacemaker but for your bladder and bowels instead of your heart. It’s a game-changer for many people giving them back control over their lives. But of course, the big question is how much of it will Medicare cover?

Does Medicare Cover Axonics Therapy

Medicare Part B usually covers medically necessary services and supplies needed to diagnose or treat a medical condition. Since Axonics Therapy is a surgical procedure that’s deemed medically necessary for some patients, Medicare covers Axonics Therapy under Medicare Part B. However coverage doesn’t mean the whole thing is free—there are still out-of-pocket costs to consider.

• Medicare Part B covers 80% of the cost of the procedure.
• The remaining 20% is usually out-of-pocket unless you have supplemental insurance.
• If you have Medicare Advantage instead of Original Medicare your coverage might vary so it’s important to check with your plan provider.

Henry Beltran, the owner of Medicare Advisors Insurance Group LLC, adds “While Medicare covers Axonics Therapy it’s crucial to understand that there are still costs involved that Medicare won’t cover. Knowing this ahead of time helps you plan financially so you’re not caught off guard.”

What are the Out-of-Pocket Costs

Out-of-pocket costs can vary depending on whether you have Original Medicare or a Medicare Advantage plan. With Original Medicare, you’ll pay 20% of the Medicare-approved amount for the procedure after meeting your Part B deductible. If you have Medicare Advantage, the copayments and coinsurance could differ, so it’s always good to double-check.

• Medicare Part B Deductible: You must meet the Part B deductible before Medicare starts paying.
• Coinsurance: After the deductible is met, you’ll be responsible for 20% of the procedure costs.
• Supplemental Insurance: If you have a Medigap policy, it could help cover the 20% coinsurance and other out-of-pocket costs.

Potential Drawbacks of Axonics Therapy

While Axonics Therapy has been a lifesaver for many, it’s not without its quirks. Like with any surgery, there are risks involved. The implantation procedure might not be everyone’s cup of tea—after all, who really wants another electronic gadget inside their body? And let’s not forget the maintenance—battery replacements could become a routine part of your healthcare calendar.

• Surgical Risks: As with any surgery, there are risks involved such as infection or device malfunction.
• Battery Replacement: The battery in the Axonics device will need to be replaced every few years, which means more surgeries down the line.
• Device Malfunction: While rare, there’s a possibility the device could malfunction, leading to more complications and possibly another surgery.

“Don’t forget,” says Henry Beltran, “that while Axonics Therapy can be very effective, it’s not a one-and-done deal. You’ll need to keep up with the maintenance like you would with a car—only this is a lot more personal.”

How to Get Coverage

Getting Medicare to cover Axonics Therapy is straightforward if the procedure is deemed medically necessary by your healthcare provider. You’ll need a referral from your doctor and possibly some documentation showing that other treatments haven’t worked for you. Once that’s all squared away, you should be good to go.

• Referral from Doctor: Ensure your doctor deems the procedure medically necessary.
• Documentation: Be prepared to show that other treatments have been tried and failed.
• Pre-authorization: Check if your Medicare Advantage plan requires pre-authorization for the procedure.

Conclusion

So there you have it—Medicare covers Axonics Therapy under Medicare Part B, but there are still out-of-pocket costs and potential drawbacks to consider. If you’re thinking about going down this road, make sure to have all your ducks in a row. And as always, if you’re unsure, reach out to us at Medicare Advisors Insurance Group LLC—we’re here to help navigate the twists and turns of Medicare coverage.

For more detailed information on Medicare coverage, feel free to visit MedicareABC.

References:

• Centers for Medicare & Medicaid Services. (2023). Medicare Coverage of Axonics Therapy.
• U.S. Department of Health and Human Services. (2023). Medicare Part B Costs.