What to Know About Medicare and Pacemaker Coverage

• A pacemaker is a battery-operated device used to correct some heart problems.

• Pacemakers are considered to be prosthetic devices, which Medicare coverage includes. The pacemaker must be deemed medically necessary in order for Medicare to cover costs.

• Medicare Advantage plans also would cover pacemakers.

• Pacemaker costs with Medicare coverage will be dependent on whether the pacemaker is implanted in either an outpatient setting or inpatient setting. 

• Medicare supplement insurance, such as a Medigap policy, may help lower out-of-pocket costs further by paying a deductible, coinsurance, or copay. This is only applicable to those with Original Medicare, however.

For those with a health condition that causes an irregular heartbeat, a pacemaker may be necessary in order to remedy the situation. But does Medicare cover pacemakers? In short, yes, Medicare will cover pacemakers because they are considered prosthetic devices and fall under durable medical equipment (DME). That said, there are rules and stipulations in place for how much Medicare pays.

This resource will explain everything Medicare beneficiaries need to know about Medicare and pacemaker coverage, including what a pacemaker is, typical costs, and more.
 

A pacemaker is a battery-operated device that assists the heart in beating regularly. The pacemaker monitors your heart rate, notices when it drops, and sends electrical impulses to correct the rhythm. Those who need a pacemaker usually have a health condition that affects their heart’s ability to beat in a normal pattern. Instead, their heart either beats too fast, too slow, or in an irregular way. A pacemaker helps remedy these types of dysregulation.

What Health Conditions Would Require a Pacemaker?

There are various types of health problems that would necessitate the use of a pacemaker. Some include: 
 

• Atrial fibrillation
• Arrhythmia
• Bradycardia
• Sinus node dysfunction (sick sinus syndrome)

Types of Cardiac Pacemakers

A pacemaker consists of two parts: a generator and wires (leads). There are three main types of pacemakers, including: 
 

• Single chamber pacemakers: This type of pacemaker has only one lead. This lead connects the pulse generator to one chamber of the heart.
• Dual-chamber pacemakers: Dual-chamber cardiac pacemakers have two leads, each one connecting to both chambers on the right side of the heart, the right atrium, and the right ventricle.
• Biventricular pacemakers: This pacemaker is also known as a cardiac resynchronization therapy (CRT) device. The CRT device consists of three leads that connect to the right atrium as well as both ventricles. Biventricular pacemakers are used for advanced stages of heart failure.

A pacemaker works by producing electrical impulses to stimulate the heart to beat, from the generator through the leads. Some newer pacemakers can also monitor your breathing and blood pressure, and can record electrical activity from the heart for a doctor to view during future appointments to make adjustments to the device if needed. A pacemaker may be planted underneath the skin via a tiny incision. Pacemaker surgery is usually a minor procedure performed on an outpatient basis. That said, if there are any issues or concerns regarding the ECG, pacemaker patients may have to stay inpatient for a day or longer.

Note: Learn more about pacemaker types and implantation at this resource.

Some pacemakers are not permanent and are external, meaning they are not surgically implanted. Instead, these external pacemakers use ​“pacing pads” that are placed on the patient’s chest to connect to the device.

Medicare is insurance provided by the federal government for certain Americans who meet Medicare eligibility requirements. The federal Medicare program consists of various Medicare plans. Some of these health insurance plans fall under Original Medicare coverage.

Original Medicare covers a cardiac pacemaker if it is medically necessary. If this is true, Medicare will need a Medicare-approved healthcare provider or physician to confirm a diagnosis to prove the device’s medical necessity in order for it to be covered. The way it is approved as medically necessary is through an National Coverage Determination (NCD) process held by the Centers for Medicare and Medicaid Services (CMS). To learn more about the NCD process for pacemakers, visit this source.

Additionally, the pacemaker supplier must also be enrolled in Medicare in order for it to be covered. Both of these parties must also accept the Medicare assignment.

If the pacemaker is, in fact, medically necessary, Medicare covers it as a prosthetic device. A prosthetic device is used to replace a body part or function. In this case, a regular heartbeat. These types of medical equipment are covered under Medicare Part B (outpatient care).

Of course, costs for pacemakers go beyond just the device itself. In the event that a cardiac pacemaker is surgically implanted and a hospital stay is needed afterward, Medicare Part A (hospital care) would also need to become involved.

Additionally, Medicare will cover replacement batteries for a pacemaker (single or dual chamber only).

Note: Learn more about Medicare coverage for pacemakers from this resource from the Centers for Medicare and Medicaid Services.

Medicare costs will vary depending on whether a pacemaker is implanted in an outpatient or inpatient setting.

Outpatient Settings

In outpatient settings, Medicare beneficiaries must pay 20% of the Medicare-approved amount for pacemakers, and the Medicare Part B deductible applies for both the pacemaker implantation as well as the device itself.

Inpatient Settings

Within inpatient settings, Medicare Part A will cover the costs. How much a Medicare beneficiary must pay for treatment costs will be determined by what benefit period they find themselves in at the time of the procedure. 
 

It is important for Medicare patients to always confirm what is covered under their specific Medicare plan with their health care plan provider or a licensed insurance agent. Other factors that may play into additional costs include:
 

• Other insurance

• How much a doctor will charge

• Whether the doctor or supplier both accept the Medicare assignment

• Future doctor visits to adjust or monitor the pacemaker

• Facility type

• What state the beneficiary lives in

Note: Learn more about prosthetic coverage and Medicare at this resource.

Medicare Advantage plans, also known as Medicare Part C or MA plans, are supplemental Medicare plans that aim to ​“fill in the gaps” of Original Medicare. Medicare Advantage plans roll up Medicare Part A and Medicare Part B into one plan and are offered via private insurance companies that are Medicare-approved. 

MA plans often also include additional benefits such as Medicare Part D (prescription drugs) as well as coverage for other medical services such as vision, dental, and hearing. These health benefits will vary per insurance plan, so beneficiaries should always consult their health insurance company to confirm. 

Because MA plans provide, at minimum, standard Orignal Medicare coverage, MA plans will cover pacemakers.

A Medicare supplement plan, also known as a Medigap or MedSupp policy, is a type of Medicare plan that helps provide additional coverage alongside Original Medicare. It may help pay some of the costs for a pacemaker. For example, many Medigap policies are sold by private insurance companies and help pay some out-of-pocket costs such as deductibles, coinsurance, and copays. This may include covering the Part B deductible amount.

Do note, someone cannot be enrolled in both a Medicare Advantage plan and a Medigap plan, as they’re both considered supplemental insurance to Medicare.