Medicare Coverage for Robotic Knee and Hip Replacement Surgery
What you need to know about your insurance before deciding on a surgeon, your implant, and a surgery facility
Financial considerations
In the decision to elect for robotics-assisted knee and hip replacement surgery, consider this:
If you have Original Medicare and a Medigap (Medicare supplemental insurance) plan, it will likely pay all or a a large portion of the 20% coinsurance for your knee replacement surgery, robotic or non-robotic.
So, the precision and accuracy of implant placement afforded by the robotic-certified surgeon using robotic-technology costs no more or less than if the surgeon uses a “computer navigation cutting guide” (e.g., “Omnibot”, not to be confused with the toy robot manufactured in themid-1980s by Tomy), or no robot at all. So why pay the same and allow your insurance to force you to accept less? And why pay the same money and agree to wait longer for a shorter service-life, lower value implant?
With the Medigap Plan C or Plan F, it will also cover the Part B deductible (the other Medigap plans do not cover the Part B deductible; this includes all Medigap plans available to beneficiaries who became eligible for Medicare after the end of 2019). So chances are high, you’ll get benefits that extend to home health, ROMTech remote physical therapy at home technologies during your recovery, home health nursing and PT assistance after surgery, and outpatient physical therapy after a few weeks of home care with little to no out of pocket expenses.
Timing considerations
When considering your options for knee and hip replacement surgery, one value consideration is projected service life of your implant. This goes far beyond monetary considerations.
Ask your surgeon how long the implant they plan to use for your surgery is expected to last.
Why it matters: If your implant only lasts 15-20 years, they may refuse to perform surgery for another 15-20 years, while you linger in pain to deal with sleep deprivation, sports and social deprivation and isolation, and agonizing pain. Is that your choice?
If they agree to perform surgery at a younger age with an inferior implant, you are knowingly consenting to a revision and it’s associated risks and costs sooner than you would with the 30-year knee or hip prosthesis.
And if you wait to a later age, you risk additional co-morbidity conditions that tend to arise with aging and genetics and lifestyle, or weight gain due to pain and inactivity, that could make the risk of having surgery outweigh the benefit, leaving you to suffer in pain and disabled until you’re healthy enough to undergo the procedure…if ever.
Only the Smith + Nephew implant is rated for a 30-year service life.
All the others are rated with a 20-year or shorter service life expectancy. Ask your surgery if they use the 30-year implant. If they don’t or say that they can’t, ask why. (Often, the surgeon’s hands are tied by the hospital where they will perform the surgery, a matter of low bid…and higher margins, to your personal detriment.)
Anatomical considerations
The computer-navigation system (Omnibot) also used in southern Utah is only capable of total knee replacement, even if only part of your knee requires resurfacing. In comparison, the Smith + Nephew robots that can be used for both total and partial knee replacements are only available at St George Surgical Center and Mesa View Regional Hospital by Dr Hicken.
Some Medicare Advantage Plans limit access to advanced robotic options
With Medicare Advantage plans, you may be limited to surgical facilities and surgeons who do not have a robotic knee or hip technology available. Many of the surgeons on their plans have not elected to hone their surgical skills with robotic certifications that are now the current state of the art. Is that what you are willing to trade by selecting a Medicare Advantage plan that doesn’t offer access to robotic knee and hip replacement surgery? It is your choice!
Your options may be limited and vary plan by plan with Medicare Advantage plans.
While Medicare Advantage plans are required to cover the knee replacement surgery, just like Original Medicare, the specifics of the coverage, choice of facilities and thus, the implant options, will vary depending on the plan. But that’s not all! Where we perform surgery in Southern Utah, they include a few other surgical amenities that benefit you in several ways:
The PICO-7, released in 2018, is an advanced wound therapy device we use to reduce your risk of infection with its AIRLOCK Technology that provides a bacterial barrier. When used uninterrupted for up to 7 days, you benefit from less pain, less swelling after surgery and fewer dressing changes. It attaches to your clothing with an integrated belt clip for full portability. It also helps your surgical wound heal faster. And, you can shower the day after surgery using this dressing without having to wrap your dressings with plastic wraps and other hassles. The PICO-7 is used on most of our surgical patients who have had robotic knee replacement. It is not used elsewhere in Southern Utah and there isn’t an extra charge for this when Dr. Hicken does your surgery. But with Medicare Advantage plans that won’t cover surgery with the robot at St George Surgical Center or Mesa View Regional Hospital, you won’t have access to a PICO-7!
EXPAREL is a non-opioid drug technology that delivers precise pain control via regional anesthesia to enhance your recovery through the first days after surgery. This medication is available to our patients having knee and hip replacement surgery. More than 9 million patients have received non-opioid EXPAREL since 2012. It works locally at the surgical site and uses a proprietary technology, which encapsulates the drugs in a suspension that is released over time. The resulting effect is that you have less pain, the pain you have will be less severe, and you consume less opioid medication after surgery. This reduces the nausea, vomiting and constipation that comes with the use of opioid medications for pain control. But if you have surgery by a surgeon and at a facility that don’t use EXPAREL because your Medicare Advantage plan won’t include those providers in their network, you won’t have access to this advanced method of non-opioid pain management.
The choice is yours and yours alone. Choose your Medicare coverage option carefully if you believe you may need a knee or hip replacement!
For example, in our clinic, we cannot obtain pre-authorization for your surgery with United Medicare Advantage HMO, SelectHealth Medicare Advantage, and several other insurers that have chosen to exclude the facilities that offer true robotic joint replacement in Southern Utah. That’s because the plans have refused to contract with us or the surgery center that invested in the robotic technology. Sadly, that means that while you have a Medicare replacement HMO plan, your coverage may not extend to out of network providers at all, and you maybe required to pay for everything associated with your surgery; not just a copayment.
Dr. Hicken and Robotic Orthopaedic Institute are committed to transparency and to
If you choose to get Medicare through Humana, United, SelectHealth, or some of the other Medicare Advantage plans, we may also experience resistance to approve home nursing and physical therapy care, the ROMTech, or even a skilled rehabilitation facility for you if you need it . That’s because fewer facilities and home care providers can contract with those companies due to community provider lock outs.
What if you choose to pay cash to have the robotic option?
The cash price of your surgery with Dr. Hicken, if you must pay for everything, is about $18,000 at St George Surgical Center plus home health, rehab admission, if necessary, medications, and remote at home therapy technologies. You’ll also need to pay for your required, medically-necessary follow up visits and X-rays.
We’d love to be in your network but in some cases, with the plans listed above, either our clinic or the facility with the robotic technology and lower infection, complications, and revision rates cannot participate due to anti-competitive constraints that exist in the marketplace forcing you, the consumer, to pay more…and get less or no benefit from your insurance.
For questions, please call our office at 435-523-3378. It would be our pleasure to explain and provide answers to clarify any of this information.