Medicare-Approved Treatment for Heart Disease

What Medicare Does and Does Not Cover

Heart disease accounts for one in four deaths in the United States. Coronary artery disease is the most common cause, accounting for 370,000 of those deaths every year.

Unfortunately, the risk for coronary artery disease increases as we age. The condition can lead to angina (chest pain), arrhythmia (an irregular heartbeat), heart failure (ineffective pumping of the heart), or a myocardial infarction (a heart attack).

Medicare covers tests that screen for common risk factors for the disease like high blood pressure and high cholesterol. However, when you already have heart disease, what will Medicare do to help you treat it?

Medicare and Chest Pain

More than seven million Americans are evaluated in the emergency room for chest pain every year. Causes of chest pain run the gamut from anxiety to heartburn to pneumonia. When your chest pain is the result of a heart problem, however, emergent care could save your life. In either case, Medicare will pay for a hospital evaluation.

The 2-Midnight Rule came into effect in 2013 and determines which part of Medicare, Part A or Part B, will cover your hospital stay.

In simple terms, if your hospital stay is expected to cross two midnights and is deemed medically necessary, i.e. the evaluation could not be safely done outside of a hospital, then Medicare Part A will pay. In this case, you are admitted as an inpatient.

If your stay is less than two midnights long or is not medically necessary, you are placed "under observation" and covered by Part B.

When it comes to Part A, you will pay an inpatient deductible of $1,364 for each hospitalization in addition to any physician fees.

When it comes to Part B, you pay 20 percent of each individual service. This includes food, intravenous lines, laboratory tests, medications, nursing care, procedures, use of the hospital bed, and more. Again, you will pay physician fees.

Although the hospital cannot charge you more than the inpatient deductible for any one service, your overall Medicare Part B costs add up quickly, often costing you more in out of pocket costs than Part A.

It is in your best interest to ask your doctor about inpatient coverage when you stay overnight in the hospital.

Medicare and Angioplasty

Cardiac catheterization is used to not only diagnose but to also treat coronary artery disease. It is a procedure that guides a small tube known as a catheter through a major vein, often the femoral vein in the leg or the jugular vein in the neck.

The catheter follows the path of blood vessels towards the heart where it then releases a dye. This dye flows into the heart and into the coronary arteries. Pictures are then taken of the dye-filled coronary arteries using fluoroscopy, an X-ray imaging technique.

Coronary arteries that ​are narrowed or obstructed increase your risk for a heart attack. Cardiac catheterization is the gold standard in diagnosing the disease.

If the blood vessels are blocked, your cardiologist can use the catheter to guide a balloon into the affected artery in a procedure referred to as balloon angioplasty. When the balloon is expanded, it can open up the narrowed artery. This may or may not have a long-lasting effect. The artery could narrow down after the balloon is removed.

Alternatively, the catheter can be used to guide a stent into the artery to hold it open long-term. There is a risk that a clot could form in the stent but that can hopefully be prevented by taking medications that thin the blood.

In the majority of cases, Medicare Part B will pay for cardiac catheterization and its associated procedures. 

This means Medicare will cover 80 percent of the cost and leave you to pay the rest. Medicare Part A will pay if you are hospitalized as an inpatient according to the 2-Midnight Rule.

Medicare and Heart Surgery

Although it is a common procedure used to treat coronary heart disease, angioplasty has its limitations. The procedure is ideal when few blood vessels are affected, but in the case of more extensive disease, a more invasive approach may provide better long-term results. In this case, you might be considered as a candidate for coronary artery bypass surgery (CABG), better known as open heart surgery.

Every year the Centers for Medicare and Medicaid Services (CMS) releases a list of surgical procedures that, regardless of the number of days you are hospitalized, will be automatically approved for inpatient care. In this case, Part A covers your procedure irrespective of the 2-Midnight Rule.

All other surgeries are categorized as outpatient procedures, even if you stay in the hospital overnight or longer. As a result, Part B will be billed.

Your doctor may make an appeal for inpatient coverage if complications occur during or immediately after your surgery. Unfortunately, there is no guarantee Medicare will agree to pay for inpatient coverage.

Being admitted as an inpatient is important not only because it keeps your out of pocket costs down but because it determines whether Medicare will pay for your care in a rehabilitation facility after you leave the hospital.

You need to be admitted as an inpatient for three consecutive days if you want Part A to pick up the costs for your stay in a rehabilitation facility. At that point, Medicare will cover the first 20 days for free but will leave you with a daily $170.50 copayment for days 21 through 60. If an extended stay is required, you will pay the full cost out of pocket to the facility.

Thankfully, CABG is covered on the inpatient-only list. Be sure to refer to this ever-changing Medicare list before you undergo any surgical procedure. It is imperative that you understand your Medicare coverage and expectations for payment.

Medicare and Cardiac Rehabilitation

It takes time to convalesce after a heart attack or heart surgery. At first, you may note increased fatigue or exercise intolerance. There may also be increased risk of anxiety and depression after an episode. Medicare recognizes these challenges and offers cardiac rehabilitation programs to support your recovery.

These programs are available if you have angina, chronic heart failure, or have had a myocardial infarction in the last 12 months. It is also inclusive to those who have undergone any of the following procedures:

These programs include physician-prescribed exercises, nutrition counseling, smoking cessation, psychosocial assessment, and an individualized treatment plan. Medicare will pay for as many as 36 sessions over 36 weeks, lasting up to an hour each. You can receive up to two sessions per day.

For those requiring more intensive rehabilitation, Medicare allows 72 one-hour sessions over an 18-week course. As many as six sessions can be approved per day. 

Where you receive care determines how much Medicare will pay.

These services must be performed in either a doctor's office or an outpatient department at a hospital. Medicare Part B pays for both locations but at different rates.

When these services are received in a doctor’s office, you will pay the standard 20 percent coinsurance for Part B services. Care rendered in a hospital outpatient department, however, is capped off. The facility can charge you no more than the Part A hospital deductible, which is $1,364 in 2019.

Medicare and Peripheral Vascular Disease

The same process of atherosclerosis that causes cholesterol and plaque to block blood flow in the heart can do the same arteries in other areas of the body, namely the abdomen, arms, head, and legs. When these vessels are obstructed, whether fully or partially, this peripheral artery disease (PAD) can cause complications like stroke, ischemic bowel, and intermittent claudication, pain in the legs with walking.

People with PAD are at considerably higher risk for heart attack, stroke, and amputation. Treatment for PAD can be expensive and invasive. 

Similar to coronary artery disease, Medicare Part B covers the majority of angioplasty and stent placement procedures, paying 80 percent of costs.

Similar to coronary artery disease, Medicare Part B covers the majority of angioplasty and stent placement procedures, paying 80 percent of costs.

Bypass surgery, however, is the more definitive treatment. Thankfully, these arterial bypass surgeries are on the inpatient-only list and covered by Part A, leaving you with a flat rate of $1,364 for the procedure and the associated hospitalization combined.

Medicare has sought to find less costly and equally effective alternatives for the treatment of PAD. As of 2018, it added supervised treadmill exercise to its list of Part B covered services for PAD-associated diagnosis codes.

Recent studies have shown that these exercises are as good as or even better in reducing pain than endovascular revascularization with angioplasty and stent placement. These workouts may not only improve your quality of life but might also reduce costly hospitalizations.

A Word from Verywell

Knowing you have heart disease means little if there is nothing you can do about it. Medicare covers an array of treatments including angioplasty, stent placement, and bypass surgery but does not cover everything. Know your options, what part of Medicare will pay (Part A or Part B), and how much you could pay out of pocket for each treatment.
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