Medicare covers defibrillators and other potentially life-saving devices.
Medicare will help pay for internal and external defibrillators and pacemakers if they are medically necessary.
If you have Original Medicare, Part A will cover inpatient procedures while Part B will cover outpatient procedures. That said, both parts may benefit you whether your surgery is inpatient or outpatient.
A Medigap policy or a Medicare Advantage plan could further help control your out-of-pocket costs if you have Parts A and B.
In the same way, Medicare will cover medically necessary replacements of approved heart-health devices.
Defibrillators have been saving lives since the 1950s. Today, surgeons can implant defibrillators, or you can wear an external defibrillator like LifeVest.
Generally speaking, if medically necessary, Medicare covers internal and external defibrillators and other heart-related devices that can save lives in an instant. [i]
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While a defibrillator is a device that delivers electricity to the heart to restore a normal heartbeat when it either stops or falls out of rhythm, a pacemaker is a device designed to maintain a normal rhythm in the first place.
If you’ve recently received a diagnosis or experienced heart trauma and have questions about Medicare coverage and defibrillator and pacemaker devices, there are a few things to know early on. The first thing is that not even all defibrillators are the same thing.
There are several different kinds of defibrillation devices. The two major types are automated external defibrillators (AEDs) and automatic implantable cardioverter defibrillators (ICDs).
While you may encounter some AEDs if you see paramedics respond to a cardiac incident or if you’re in a shopping mall that makes one available in case of emergency, the AEDs typically covered by Medicare are ones like a LifeVest device that individuals wear externally for their own peace of mind.
ICDs are implanted and used if a patient is at high risk of their heart not beating properly. If your heart is beating too fast or too slow or irregularly, you risk damaging your heart. An ICD is a small electronic device connected to the heart and responds to irregular heart rhythms. The device can correct heart rhythms or provide a shock to prevent cardiac arrest.
A pacemaker is a small device that’s placed in your chest to help control your heartbeat. It’s used to help your heart beat more regularly if you have an irregular heartbeat (arrhythmia), particularly a slow one. A pacemaker can also be implanted temporarily to treat a slow heartbeat after a heart attack, surgery or medication overdose. In some cases, a pacemaker will be implanted permanently to correct an irregular heartbeat and treat heart failure.
The latest internal defibrillators are capable of doubling as pacemakers. But while both devices deliver electrical pulses to the heart, pacemakers can’t do what defibrillators can.
Medicare may help you pay the costs related to a defibrillator (internal or external) or a pacemaker if you’ve been diagnosed with heart failure.
If you need a defibrillator, the Centers for Medicare and Medicaid Services (CMS) says, ” Medicare may cover an implantable automatic defibrillator if you’ve been diagnosed with heart failure.”
That’s the good news and the simple answer to the question, ” Does Medicare cover defibrillators?” Of course, it’s not quite that simple.
Medicare Part A pays if the surgery takes place in a hospital inpatient setting. If your doctor or provider admits you to the hospital for an overnight “hospital stay” or longer, your care is considered inpatient.
Medicare Part B pays if the surgery takes place in a hospital outpatient setting. An outpatient setting is also called ambulatory care, and it’s the opposite of inpatient care. Any treatment or service you receive that does not require being admitted to the hospital is considered outpatient.
The Centers for Medicare & Medicaid Services (CMS) first issued a National Coverage Determination for implanted automatic defibrillators in 1986 and has updated it multiple times over the years. [i] The purpose of a National Coverage Determination (NCD) is to define the qualifications required for Medicare coverage of a condition and related services and equipment. (CMS first issued an NCD for cardiac pacemakers a year earlier, in 1985 [i] ).
The latest version of the NCD regarding Medicare coverage of defibrillators describes six “covered indications” and other qualifications. In simple terms, the NCD spells out what makes the use of a defibrillator medically necessary. The complexity of the analysis means that you aren’t going to be approved for an implanted heart device merely with a doctor’s note. A cardiologist or similar specialist needs to be involved in your treatment.
The good news is that if you have concerns about your heart, Medicare will help pay for you to get a proper assessment.
Are you eligible for cost-saving Medicare subsidies?
While Medicare covers internal defibrillators as “permanent” treatments for heart failure, those waiting for surgery may benefit from an FDA-approved external defibrillator. [i] So, does Medicare cover LifeVest defibrillators?
If you are a Medicare beneficiary with a heart condition and want your doctor to recommend LifeVest as a treatment, you’ll be required to meet certain guidelines to be eligible. First, you’ll need to show that LifeVest as a treatment option is a medical necessity. Second, you’ll likely need your cardiologist to provide a record of a qualifying heart condition and confirmation that it’s medically necessary. In this instance, a specialist and not your primary care provider must provide the recommendation.
Medicare may only cover a wearable defibrillator like LifeVest for temporary use while waiting for a “permanent” implantable device and surgery. If Medicare approves temporary treatment with LIfeVest, any related equipment, delivery, repair, parts and supplies for the device are covered with an approved rental agreement.
In 2014, CMS issued a Local Coverage Determination (LCD) for automatic external defibrillators (AEDs) that has been updated multiple times. [i] Much like a National Coverage Determination, an LCD defines the qualifications required for Medicare coverage of a condition and related services and equipment (the difference is found in the behind-the-scenes approval process).
The LCD doesn’t discuss exactly how AEDs are to be covered. Still, Medicare coverage of wearable defibrillator s commonly comes in the form of assistance with the cost of a rental in advance of surgery.
A study by the University of California at Berkeley found that costs associated with implanting a defibrillator can top $55,000.
That was in 2008.
Today, the final costs associated with inserting a defibrillator can vary by tens of thousands of dollars depending on where you have the procedure, your physical condition, surgical or recovery complications, and additional tests required to safely manage your care. For example, a Cleveland Clinic outpatient facility lists the cost for “insertion of cardiac defibrillator” between $38,580 to $57,880 in 2020. [i] However, complications or additional procedures during a defibrillator surgery could increase the cost beyond the estimate.
Keep in mind that you can always contact your provider or the facility providing your services to request an estimate of the costs for your care. Again, an estimate is not guaranteed to be the final cost you will pay. If you have Original Medicare or a Medicare Advantage plan, your out-of-pocket costs will depend on your coverage
Medicare makes it possible for people to afford a defibrillator.
- If your Medicare-approved procedure qualifies as an inpatient hospital stay (as many do), Medicare Part A will cover you. As is typical of Part A, as long as your stay is 60 days or less, your responsibility will be to pay the benefit period deductible ($1,556 in 2022). There may be other costs around the hospital stay that you and/or other parts of Medicare (often Part B) must cover.
- If your Medicare-approved procedure qualifies as outpatient, Medicare Part B will cover you, although you may also owe the Part B deductible. As is typical of Part B, Medicare will pay 80% of costs after paying your annual deductible ($233 in 2022). You pay the other 20% in the form of coinsurance.
- Costs under Part B can add up because it doesn’t feature an out-of-pocket maximum. If you have Parts A and B of Original Medicare, you can add a Medigap supplemental plan. All 10 standard Medigap plans pay at least 50% of Part B coinsurance, and two of them feature the protection of an out-of-pocket maximum.
- If you have a Medicare Advantage plan — which replaces Parts A and B while offering at least the same coverage — then you already have an out-of-pocket maximum. Your financial responsibilities will vary based on your specific plan.
How much does an AED cost?
The retail price of an AED will vary based on the type of AED and the device maker. If you are planning to buy an AED, you should be prepared for a price tag between $1,500 to $2,000. You may be able to find an AED for less, but this price range is near the average for a reliable device. The Food and Drug Administration (FDA) provides and approves all guidelines for the manufacturing of AEDs, and the FDA may require you to have a physician’s prescription to purchase certain devices.
However, since you usually need an automated external device for 90 days or less in advance of getting an internal defibrillator, renting may make the most sense. Medicare Part B will help with your costs if you qualify for medically necessary durable medical equipment, covering 80% of the price after paying your annual deductible. You then pay 20% coinsurance.
When you’re ready to purchase an AED, it’s important to review the features of each device. Not all AEDs are the same, and slightly different features from one AED to the next may make a difference to whether a device meets your needs. If you’re interested in more information about safely using your AED after purchase, The American Heart Association offers CPR AED eLearning courses.
What extra benefits and savings do you qualify for?
When the time approaches to replace the battery in a pacemaker, you must replace the entire pacemaker. That’s typically after five to seven years or more, both when it comes to pacemakers and internal defibrillators. [i]
Assuming a new device is still medically necessary, the replacement device will be covered by Medicare the same way the original was.