Does Medicare Cover Shoulder Replacement Surgery?

Health Line

4 hours ago

Key takeaways
Original Medicare (parts A and B) covers shoulder replacement surgery when a doctor certifies it as medically necessary. Part A covers open surgeries, and Part B covers arthroscopic procedures.
To qualify for coverage, you must have a specific diagnosis, such as a degenerative joint disease, post-traumatic arthritis, or rotator cuff injury, along with evidence of chronic pain or disability lasting at least 12 weeks.
Out-of-pocket costs include deductibles, coinsurance, and copayments, even with Medicare coverage. In 2025, the deductible for inpatient surgery under Part A is $1,676 per benefit period. Part B has a $257 annual deductible plus a 20% coinsurance on Medicare-approved costs.
Your shoulder is a flexible joint that's highly susceptible to injury and wear and tear. A severely damaged shoulder could affect your quality of life. Even so, shoulder replacement surgery is often categorized as elective.
Because Medicare doesn't typically cover elective surgeries, you may be concerned that you'll have to live with pain or pay for the surgery out of pocket.
But Medicare will, in fact, pay for a portion of the costs if your doctor states that shoulder replacement surgery is medically necessary in your specific case.
Is a shoulder replacement covered by Medicare?
You might need shoulder replacement surgery to repair your shoulder or to reduce further damage to the joint.
Your doctor must certify that your surgery is required to heal or prevent ongoing damage caused by a disease, such as arthritis. This doctor must also be enrolled in and approved by Medicare.
Keep in mind that you'll need to meet your deductible and pay your share of coinsurance or copayments. To avoid surprises, it's also a good idea to confirm the details of your coverage with Medicare or your supplemental plan.
Here's what's covered under each part of Medicare:
Medicare Part A coverage
Open surgery is an invasive option that requires a surgeon to make a large incision to repair or replace your shoulder.
If your open shoulder replacement is medically necessary, Medicare Part A will cover a portion of the cost. Part A is one part of Original Medicare.
Part A will also cover any medications or therapies you receive during your stay at a hospital, skilled nursing facility, or rehabilitation center, but there are limits to how long Medicare will cover a stay at any type of inpatient facility.
Medicare Part B coverage
Shoulder surgery may also be performed arthroscopically. This minimally invasive procedure is typically performed in a hospital or freestanding clinic on an outpatient basis.
If you have an arthroscopic shoulder replacement, your surgeon makes a small incision in your shoulder and places a small camera there. Through another small incision, your surgeon repairs or replaces portions of your shoulder.
If your arthroscopic shoulder replacement surgery is medically necessary, Medicare Part B — the other part of Original Medicare — will cover a portion of the cost.
Part B also covers these items and services as well, if needed:
all of your doctors' appointments before and after surgery
physical therapy following surgery, which you'll need no matter what type of procedure you have
any durable medical equipment you need after surgery, such as an arm sling
Medicare Part C coverage
If you have Medicare Part C (Medicare Advantage), your plan will cover all the expenses covered by Original Medicare (parts A and B). Depending on your plan, it may also cover prescription drugs.
If you have a Part C plan, it's important to use in-network healthcare professionals and pharmacies to lower your out-of-pocket costs.
Medicare Part D coverage
Medicare Part D covers any drugs prescribed for you to take after surgery, such as pain medication. It is optional prescription drug coverage offered through Medicare.
Each Part D plan includes a formulary. This is a list of medications that the plan covers and the percentage of coverage you can expect.
Medigap coverage
If you have Original Medicare, you might also have a Medigap plan. Depending on your plan, Medigap may cover some of the remaining out-of-pocket costs for your shoulder replacement surgery. This can include your copays, coinsurance, and deductibles.
Medigap typically covers medication copays through Part D. Note, though, that most plans are not allowed to cover the Part B premium.
How do you qualify for shoulder replacement?
The Centers for Medicare & Medicaid Services (CMS) consider shoulder replacement surgery as medically necessary when you have a diagnosis of various conditions, including degenerative joint diseases like osteoarthritis, post-traumatic arthritis, and rotator cuff injury.
To qualify, you'll need to provide medical records showing the diagnosis through imaging. You'll also need to show evidence of living with chronic pain or disability for at least 12 weeks as a result of the condition and a history of other treatments that were unsuccessful.
Other situations that may require this procedure include acute fractures or tumor removals. Medicare may ask you to do physical therapy before approving surgery in some cases. Reverse surgery may also be necessary after previous failed procedures.
What are the out-of-pocket costs for covered procedures?
It may be difficult to estimate your exact out-of-pocket costs before your procedure.
Your doctor's billing office should be able to give you a written estimate of what you can expect. This usually includes a range of potential costs based on the services you might require during and immediately after the procedure.
Original Medicare costs
There are out-of-pocket costs that you can expect, even if you have Medicare. These include:
Medicare Part A premium: Most people pay no premium for Part A because they paid Medicare taxes long enough while working. However, if you or your spouse did not work at least 40 quarters of Medicare-covered employment (10 years), you may pay a premium of $285 or $518 in 2025, depending on how long you or your spouse paid Medicare taxes.
Inpatient surgery: Your Part A inpatient hospital deductible is $1,676. This covers the first 60 days of Medicare-covered inpatient hospital care in a benefit period.
Coinsurance: If you require a longer stay, you will pay a coinsurance amount of $419 daily from day 61 through day 90 in a benefit period and $838 daily for any lifetime reserve days you use.
Skilled nursing facility care: If you stay in a skilled nursing facility, your daily coinsurance cost from day 21 through day 100 in a benefit period would be $209.5 per day.
Outpatient surgery: For outpatient surgery, you're responsible for meeting your Part B annual deductible of $257, as well as your monthly premium, which is $185 for most people in 2025.
Medicare-approved costs: You'll pay 20% of the Medicare-approved cost of the outpatient procedure.
Durable medical equipment and physical therapy: You'll also pay 20% of the costs for any durable medical equipment and physical therapy appointments.
Medicare Part C costs
If you have Medicare Part C, your costs will vary depending on the type of plan you have. Your insurer can give you specific coverage and copay details ahead of time. Typically, you can expect to pay some form of copay.
No matter which type of Part C plan you have, it's legally required that your plan cover at least as much as Original Medicare. This includes the costs of inpatient or outpatient surgery.
Medicare Part D costs
If you have Medicare Part D, your costs will differ based on your plan. You will most likely have some copay costs for any medications prescribed for you.
Your plan's formulary and tier system set the costs per drug. Your plan provider can let you know what you will pay for each medication ahead of time.
Tip
Medicare has a procedure price lookup tool, which could help you determine the cost of an outpatient surgery. To get the most accurate results, ask your doctor for the exact name of the procedure or the code for that type of surgery.
Frequently asked questions
What is the average cost of shoulder replacement surgery without insurance?
According to research from 2018, total shoulder replacement has a mean total out-of-pocket cost of $14,000 to $52,000 per patient.
How long does it take for the elderly to recover from shoulder replacement surgery?
Generally, Most people can resume gentle daily activities within 2 to 6 weeks after the surgery and more strenuous sports within about 6 months. That said, older adults may take longer to recover.