Does Medicare Cover Stem Cell Therapy? 

You may have heard about stem cells in the news over the past few decades, and more specifically, you may have heard about stem cell therapy. Stem cells serve as blank canvases from which specific cells can form. When a stem cell divides, it can form daughter cells which either become more stem cells or particular types of cells for the formation of organs and tissue.

Stem cell therapy involves the manipulation and transplant of stem cells in an attempt to allow the body to heal from illness and injury naturally. By injecting stem cells into the body, these cells have the potential to repair damaged tissue by replacing dead or damaged cells with new ones. This is often referred to as regenerative medicine, and new therapies are always being tested and developed.

How does Medicare cover stem cell therapy?

Original Medicare benefits provide coverage for a number of common medical treatments, but since stem cell therapy is relatively new, Medicare recipients often wonder whether the program covers stem cell therapy. Before looking at Medicare coverage options for stem cell treatments, it’s first important to understand how Medicare decides what to cover.

Medicare coverage includes separate parts. These are Medicare Part A, Medicare Part B, Medicare Part C (Medicare Advantage) and Medicare Part D. Enrollment in Medicare Part A is usually automatic upon reaching age 65, but Medicare Parts B and D are optional coverage. Part C is an alternative to Original Medicare.

Medical necessity and Medicare coverage of stem cell therapy

For any type of Medicare coverage, treatments must be considered medically necessary. This means that cosmetic treatments for weight loss surgery and lifestyle treatments like Viagra are usually not covered. When it comes to coverage for stem cell therapy, your doctor will need to prescribe the treatment and document that they believe the treatment is medically necessary to preserve life or to treat, cure or prevent disease.

Medicare covers stem cell therapy that is medically necessary under Part B in most cases. As this is the outpatient portion of Medicare, it covers medical treatments administered in a doctor’s office or clinical setting, but it also covers lab and diagnostic testing. Because stem cell therapy often involves injections and transplantation, both of which take place in an outpatient setting, Medicare Part B will provide coverage for these types of therapy.

Medicare Part B costs include a monthly premium and a deductible. Your plan’s premium will typically be based on your income according to your tax filings. A deductible amount is an amount you must spend on Medicare-approved healthcare costs each benefit period before your benefits begin to apply toward your medical care.

Inpatient stem cell therapy coverage

If you receive stem cell therapy while hospitalized, Medicare Part A may provide coverage instead. This can require that you stay at least two midnights in a hospital or skilled nursing facility in order to qualify. This is referred to as the two-midnight rule. If you simply receive stem cell treatment at a hospital, Part A does not apply since Part A requires that you be admitted.

Most Medicare recipients receive Part A coverage with no premium required. If you do not receive premium-free Medicare Part A, you will be subject to a set monthly cost that may change from year to year. Additionally, Medicare Part A has a deductible that must be met per benefit period.

Medicare Part D and stem cell therapy

Because stem cell therapy may involve prescription medications depending on whether you require supportive therapy, Medicare Part D may cover medications involved in your treatment. In most cases, Medicare Part D only covers drugs that are listed in each plan’s formulary. If your prescribed medication is not listed in your Part D formulary, you may be able to work with your doctor to get an exception waiver.