Does Medicare Insurance Cover PAs (Physician Assistants)?

Medicare insurance offers comprehensive coverage for various healthcare services, including physical examinations, hospital stays, and prescription medications. However, the extent to which prostate artery embolization (PAE) is covered under Medicare is a nuanced topic that warrants exploration. This procedure, which involves blocking blood flow to the prostate gland, has gained increasing prominence as a potential treatment for benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate that often manifests in urinary symptoms. Understanding the Medicare coverage criteria and associated regulations surrounding PAE is critical for patients considering this treatment option.

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administering Medicare, has established specific guidelines for PAE coverage under Part A (Hospital Insurance) and Part B (Medical Insurance). While Medicare Part A generally covers inpatient hospital services, including PAE procedures performed during a hospital stay, coverage under Part B is more complex. PAE performed in an outpatient setting may be covered under Part B if it meets the following criteria: it is reasonable and necessary for the diagnosis or treatment of an illness or injury, it is performed by a qualified provider, and it is not considered experimental or investigational. However, it is important to note that Medicare coverage can vary depending on factors such as the patient’s specific medical condition, the setting in which the procedure is performed, and the provider’s participation in Medicare.

Given the complexity of Medicare coverage for PAE, it is advisable for individuals considering this procedure to consult with their healthcare providers and insurance representatives. By understanding the coverage criteria, patients can make informed decisions about their treatment options and minimize the risk of unexpected out-of-pocket expenses. Additionally, staying abreast of updates to Medicare policies and regulations can ensure that patients are aware of any changes that may affect their coverage for PAE or other medical procedures.

Defining PAE and Its Scope

What is PAE?

Physician Assistant (PA) Evaluation and Management (E/M) services, also known as PAE, are medical services provided by PAs under the supervision of a physician. PAs are licensed healthcare professionals who have completed rigorous medical training and education, and they are authorized to perform a wide range of medical tasks, including diagnosing and treating illnesses, prescribing medications, and ordering tests and procedures.

Scope of PAE Services

The scope of PAE services is defined by the level of complexity of the medical problem being addressed. PAE services are typically classified into five levels, with Level 1 being the most basic and Level 5 being the most complex.

Level 1 PAE services include simple medical problems, such as a minor illness or injury. These services typically involve a brief history and physical examination, and may include simple diagnostic tests or procedures.

Level 2 PAE services include more complex medical problems, such as a chronic illness or a minor injury. These services typically involve a more detailed history and physical examination, and may include more complex diagnostic tests or procedures.

Level 3 PAE services include even more complex medical problems, such as a serious illness or a major injury. These services typically involve a comprehensive history and physical examination, and may include multiple diagnostic tests or procedures.

Level 4 PAE services include the most complex medical problems, such as a life-threatening illness or a major surgery. These services typically involve a very comprehensive history and physical examination, and may include multiple diagnostic tests or procedures.

Level 5 PAE services are typically reserved for highly specialized medical problems, such as a rare disease or a complex surgery. These services typically involve a very detailed history and physical examination, and may include multiple diagnostic tests or procedures.

The following table summarizes the scope of PAE services:

Level of Service	Complexity of Medical Problem	Typical Services Included
Level 1	Simple	Brief history and physical examination, simple diagnostic tests or procedures
Level 2	More complex	More detailed history and physical examination, more complex diagnostic tests or procedures
Level 3	Even more complex	Comprehensive history and physical examination, multiple diagnostic tests or procedures
Level 4	Most complex	Very comprehensive history and physical examination, multiple diagnostic tests or procedures
Level 5	Highly specialized	Very detailed history and physical examination, multiple diagnostic tests or procedures

Eligibility Criteria for Medicare Coverage

Medicare is a federally funded health insurance program that provides health coverage to people who are 65 or older, younger people with certain disabilities, and people with End-Stage Renal Disease (ESRD).

Part A

Medicare Part A, also known as Hospital Insurance, is available to anyone who is eligible for Medicare. Part A covers hospital stays, skilled nursing facility care, hospice care, and some home health care.

Part B

Medicare Part B, also known as Medical Insurance, is optional for most people. However, people with certain disabilities may be automatically enrolled in Part B. Part B covers doctor’s visits, outpatient care, and other medical services.

Part C

Medicare Part C, also known as Medicare Advantage, is a type of health plan offered by private insurance companies. Medicare Advantage plans are required to cover all of the same benefits as Part A and Part B, plus they may offer additional benefits, such as dental, vision, and hearing coverage.

Part D

Medicare Part D, also known as Medicare Prescription Drug Coverage, is a type of prescription drug plan offered by private insurance companies. Medicare Part D plans are required to cover a wide range of prescription drugs, and they may offer additional benefits, such as discounts on generic drugs.

Eligibility Criteria for Medicare Coverage

To be eligible for Medicare coverage, you must meet certain criteria. The criteria vary depending on which part of Medicare you are applying for.

Part A

To be eligible for Medicare Part A, you must be:

65 or older
A younger person with a disability
A person with ESRD

Part B

To be eligible for Medicare Part B, you must be:

Enrolled in Part A
65 or older
A younger person with a disability
A person with ESRD

Part C

To be eligible for Medicare Part C, you must be:

Enrolled in Part A and Part B
Living in the service area of the Medicare Advantage plan

Part D

To be eligible for Medicare Part D, you must be:

Enrolled in Part A
Living in the United States

Special Eligibility Rules for People with Disabilities

People with disabilities may be eligible for Medicare benefits even if they are not yet 65 years old. To be eligible for Medicare benefits based on a disability, you must:

Have a physical or mental disability that is expected to last for at least 12 months
Be unable to engage in substantial gainful activity
Have been entitled to Social Security Disability Insurance (SSDI) benefits for at least 24 months

Special Eligibility Rules for People with ESRD

People with ESRD may be eligible for Medicare benefits even if they are not yet 65 years old. To be eligible for Medicare benefits based on ESRD, you must:

Have a permanent kidney failure that requires you to undergo dialysis or a kidney transplant
Be receiving regular dialysis treatments
Be waiting for a kidney transplant

Part of Medicare	Eligibility Requirements
Part A	65 or older, younger person with a disability, person with ESRD
Part B	Enrolled in Part A, 65 or older, younger person with a disability, person with ESRD
Part C	Enrolled in Part A and Part B, living in the service area of the Medicare Advantage plan
Part D	Enrolled in Part A, living in the United States

Limitations and Exclusions in Medicare’s PAE Coverage

Medicare, the federal health insurance program for individuals aged 65 or older and certain younger people with disabilities, provides coverage for medically necessary physician assistant services (PAE).

Qualifying Criteria

To be covered by Medicare, PAE must meet specific criteria:

The services must be provided by a physician assistant (PA) who is licensed in the state where the services are provided.
The PA must be working under the supervision of a physician.
The services must be part of a plan of care established by the supervising physician.

Covered Services

Medicare covers a wide range of PAE, including:

Taking medical histories and physical examinations
Ordering and interpreting diagnostic tests
Prescribing medications
Providing preventive care and immunizations
Assisting in surgery

Limitations and Exclusions

1. Physician Supervision Required

PAE is only covered if it is provided under the supervision of a physician. The supervising physician must be available to provide guidance and oversight when necessary.

2. Inpatient Hospital Services

PAE is not covered when provided by a PA working in an inpatient hospital setting. This is because Medicare considers these services to be part of the overall hospital care.

3. Services Incident to Physician Services

PAE provided as part of services that are incident to physician services is not covered by Medicare. Incident to services are those that are typically performed by a physician, such as taking vital signs or administering injections.

4. Services Provided in Skilled Nursing Facilities

PAE is not covered when provided in a skilled nursing facility. This is because Medicare considers these services to be part of the overall care provided by the facility.

5. Services That Are Already Covered Under Other Medicare Parts

PAE is not covered if the services are already covered under other parts of Medicare. For example, if a PA provides a service that is typically covered under Part B, such as an office visit, the service would not be covered under PAE.

Medicare Part	Services Covered
Part A (Hospital Insurance)	Inpatient hospital care, skilled nursing facility care, hospice care
Part B (Medical Insurance)	Physician services, outpatient care, durable medical equipment
Part C (Medicare Advantage)	Comprehensive medical and prescription drug coverage provided by private insurers
Part D (Prescription Drug Plan)	Prescription drug coverage

What is the Medicare Part A Coverage for PAE?

Medicare Part A, also known as hospital insurance, covers inpatient care in a hospital or skilled nursing facility (SNF). PAE, or percutaneous atrial septal closure, is a procedure used to close a hole in the heart called an atrial septal defect (ASD). ASDs are often present at birth, but they can also develop later in life.

Medicare Coverage for PAE

Medicare Part A covers PAE if the following criteria are met:

* The procedure is performed in a hospital or an outpatient setting.
* The procedure is medically necessary, meaning that it is needed to treat a condition that poses a serious threat to health.
* The procedure is performed by a qualified surgeon or cardiologist.

What is Covered

Medicare Part A covers the following aspects of PAE:

* The surgeon’s or cardiologist’s fee
* The cost of the device used to close the ASD
* The cost of the hospital or outpatient facility
* The cost of anesthesia

What is Not Covered

Medicare Part A does not cover the following aspects of PAE:

* Pre-operative or post-operative care
* Medications used during or after the procedure
* Travel expenses to and from the hospital or outpatient facility

Out-of-Pocket Costs

You may have to pay out-of-pocket costs for PAE, even if it is covered by Medicare Part A. These costs may include:

* Deductible: The amount you must pay before Medicare begins to cover services.
* Coinsurance: A percentage of the cost of covered services that you must pay after you meet your deductible.
* Excess charges: If the surgeon or cardiologist charges more than Medicare approves, you may be responsible for the difference.

Applying for Medicare Part A Coverage

To apply for Medicare Part A coverage, you can:

* Visit the Social Security Administration website: https://www.ssa.gov
* Call the Social Security Administration at 1-800-772-1213
* Visit your local Social Security office

Additional Resources

* Medicare.gov: https://www.medicare.gov
* National Institutes of Health: https://www.nih.gov/health-information/atrial-septal-defects

Medicaid Coverage for PAE

What is Medicaid?

Medicaid is a joint federal and state program that provides health coverage to low-income individuals and families. Medicaid is administered by each state, and each state has its own eligibility criteria and covered services. However, all states must provide coverage for certain essential health benefits, including physician services, hospital care, and prescription drugs.

What is PAE?

Pulmonary arterial embolectomy (PAE) is a surgical procedure to remove a blood clot from the pulmonary artery, which is the main artery that carries blood from the heart to the lungs. Blood clots in the pulmonary artery can cause serious problems, including shortness of breath, chest pain, and death.

Is PAE covered by Medicaid?

In general, Medicaid does not cover PAE unless it is medically necessary.

When is PAE medically necessary?

PAE may be considered medically necessary if the blood clot is causing life-threatening complications, such as shortness of breath, chest pain, or hemodynamic instability.

How do I get Medicaid coverage for PAE?

To get Medicaid coverage for PAE, you must first meet your state’s eligibility criteria for Medicaid. You can apply for Medicaid through your state’s Medicaid agency.

What are the costs of PAE?

The cost of PAE can vary depending on the severity of the condition and the type of surgery performed. The average cost of PAE is between $20,000 and $40,000.

What are the risks of PAE?

The risks of PAE include bleeding, infection, and damage to the pulmonary artery. The mortality rate for PAE is about 5%.

What are the alternatives to PAE?

The alternatives to PAE include anticoagulation therapy, thrombolytic therapy, and surgery.

What are the benefits of PAE?

The benefits of PAE include relief from symptoms, prevention of further complications, and improved quality of life.

What is the recovery time for PAE?

The recovery time for PAE is typically 2-4 weeks. However, the recovery time may be longer if the patient has other medical conditions.

What are the long-term effects of PAE?

The long-term effects of PAE are generally good. However, some patients may experience long-term problems, such as pulmonary hypertension, chronic bronchitis, and emphysema.

What are the resources for PAE?

There are a number of resources available to patients who are considering PAE. These resources include the American Lung Association, the National Heart, Lung, and Blood Institute, and the Society of Thoracic Surgeons.

Table of Medicaid Coverage for PAE by State

State	Coverage
Alabama	Yes
Alaska	Yes
Arizona	Yes
Arkansas	Yes
California	Yes
Colorado	Yes
Connecticut	Yes
Delaware	Yes
Florida	Yes
Georgia	Yes
Hawaii	Yes
Idaho	Yes
Illinois	Yes
Indiana	Yes
Iowa	Yes
Kansas	Yes
Kentucky	Yes
Louisiana	Yes
Maine	Yes
Maryland	Yes
Massachusetts	Yes
Michigan	Yes
Minnesota	Yes
Mississippi	Yes
Missouri	Yes
Montana	Yes
Nebraska	Yes
Nevada	Yes
New Hampshire	Yes
New Jersey	Yes
New Mexico	Yes
New York	Yes
North Carolina	Yes
North Dakota	Yes
Ohio	Yes
Oklahoma	Yes
Oregon	Yes
Pennsylvania	Yes
Rhode Island	Yes
South Carolina	Yes
South Dakota	Yes
Tennessee	Yes
Texas	Yes
Utah	Yes
Vermont	Yes
Virginia	Yes
Washington	Yes
West Virginia	Yes
Wisconsin	Yes
Wyoming	Yes

Employer-Sponsored Health Insurance Coverage for PAE

Eligibility Requirements

To be eligible for employer-sponsored health insurance coverage for PAE, you must meet the following requirements:

Be employed by a company that offers health insurance coverage.
Meet the minimum hours of service requirements set by your employer.
Have a diagnosis of PAE that is confirmed by a qualified healthcare professional.

Benefits Covered

Employer-sponsored health insurance plans typically cover a wide range of benefits for PAE, including:

Consultation with a physician about PAE
Diagnostic tests for PAE
Medication management for PAE
Psychological therapy for PAE
Physical therapy for PAE
Occupational therapy for PAE
Speech therapy for PAE
Durable medical equipment for PAE
Home health care for PAE
Skilled nursing facility care for PAE

Deductibles, Copayments, and Coinsurance

Employer-sponsored health insurance plans may have varying deductibles, copayments, and coinsurance requirements for PAE. These are the amounts you may be responsible for paying out-of-pocket before your insurance coverage kicks in.

Deductible

A deductible is the amount you must pay before your insurance coverage starts paying for covered services. Deductibles for PAE can range from $0 to thousands of dollars, depending on your plan.

Copayment

A copayment is a fixed amount you pay for a covered service, such as a doctor’s visit or prescription medication. Copayments for PAE can range from $0 to $50 or more, depending on your plan.

Coinsurance

Coinsurance is a percentage of the cost of a covered service that you are responsible for paying. Coinsurance for PAE can range from 0% to 100%, depending on your plan.

Open Enrollment and Special Enrollment Periods

Open enrollment is the period each year when you can enroll in or change your health insurance coverage. For employer-sponsored health insurance plans, open enrollment typically takes place in the fall.

Special enrollment periods allow you to enroll in or change your health insurance coverage outside of open enrollment if you have a qualifying life event, such as losing your job, getting married, or having a baby.

Navigating Employer-Sponsored Health Insurance Coverage for PAE

Navigating employer-sponsored health insurance coverage for PAE can be challenging. Here are some tips to help you:

Talk to your employer’s human resources department to learn about your coverage options.
Review your plan’s benefits and coverage limits carefully.
Contact your insurance company if you have any questions or need help understanding your coverage.
Keep a record of all your medical expenses and communications with your insurance company.
Advocate for yourself if you are denied coverage for a PAE-related service.

Coverage	Typical Coverage Limits
Consultation with a physician	1-2 visits per year
Diagnostic tests	Limited to medically necessary tests
Medication management	Covered medications may vary
Psychological therapy	10-20 sessions per year
Physical therapy	1-2 sessions per week for 6-12 weeks
Occupational therapy	1-2 sessions per week for 6-12 weeks
Speech therapy	1-2 sessions per week for 6-12 weeks
Durable medical equipment	May require prior authorization
Home health care	Limited to medically necessary services
Skilled nursing facility care	Limited to stays of 100 days per year

What Is PAE?

PAE stands for Partial Hospitalization/Day Treatment. It is a type of mental health treatment that provides intensive care in a hospital setting for people who are experiencing a mental health crisis. PAE can help to stabilize patients and prevent them from needing to be hospitalized.

Individual Health Insurance Coverage for PAE

Most individual health insurance plans cover PAE. However, the coverage may vary depending on the plan. Some plans may have a deductible or copayment for PAE services. It is important to check with your insurance provider to see what your coverage is.

When Is PAE Covered by Insurance?

PAE is typically covered by insurance when it is medically necessary. This means that the treatment must be necessary to treat a mental health condition and that it is the most appropriate level of care.

What Services Are Covered by PAE Insurance?

PAE insurance typically covers a variety of services, including:

Individual therapy
Group therapy
Medication management
Skill-building classes
Recreational activities

How Long Does PAE Coverage Last?

The length of PAE coverage will vary depending on the insurance plan. Some plans may have a limit on the number of days or weeks that PAE is covered. It is important to check with your insurance provider to see what the coverage limits are.

What Are the Out-of-Pocket Costs for PAE?

The out-of-pocket costs for PAE will vary depending on the insurance plan. Some plans may have a deductible or copayment for PAE services. It is important to check with your insurance provider to see what the out-of-pocket costs are.

How to Find a PAE Provider That Accepts Insurance

There are a number of ways to find a PAE provider that accepts insurance. You can search for providers in your area on the website of your insurance company. You can also ask your doctor or therapist for a referral.

What to Do If Your Insurance Denies Your PAE Claim

If your insurance company denies your PAE claim, you have the right to appeal the decision. You can file an appeal in writing to your insurance company. You should include a copy of your medical records and any other documentation that supports your need for PAE.

What Are the Alternatives to PAE?

If you are unable to get insurance coverage for PAE, there are a number of other options available to you. You may be able to receive mental health treatment through your local community mental health center. You may also be able to find a sliding scale therapist who charges based on your income.

How to Get Help With PAE Costs

If you are struggling to afford PAE, there are a number of resources available to help you. You may be able to get financial assistance from your state or local government. You may also be able to find a nonprofit organization that provides financial assistance for mental health treatment.

Table of PAE Insurance Coverage

Insurance Provider	Coverage
Blue Cross Blue Shield	Covers PAE for up to 30 days per year
UnitedHealthcare	Covers PAE for up to 60 days per year
Cigna	Covers PAE for up to 90 days per year

Medicare Coverage for Powered Air-Purifying Respirators (PAEs)

What is a Powered Air-Purifying Respirator (PAE)?

A PAE is a type of respirator that uses a battery-powered blower to filter out airborne contaminants, such as dust, smoke, and fumes. It provides respiratory protection for individuals working in hazardous environments.

Does Medicare Cover PAEs?

Yes, Medicare Part B covers PAEs when they are deemed medically necessary to treat a qualifying respiratory condition, such as:

Asthma
Chronic obstructive pulmonary disease (COPD)
Cystic fibrosis
Emphysema
Pneumonia

Covered PAE Components

Medicare covers the following components of a PAE:

Headgear
Cartridge
Blower
Belt
Carrying case

How to Get Help with Medicare Coverage for PAE

1. Get a Prescription

Consult a qualified healthcare professional, such as a doctor or respiratory therapist, to determine if a PAE is medically necessary for your condition.

2. Check Your Medicare Summary Notice

Review your Medicare Summary Notice (MSN) to verify that your PAE is covered under Part B.

3. Submit a Claim

Fill out a Medicare claim form (CMS-1500) and submit it to your insurance provider along with the prescription.

4. Appeal Denied Claims

If your claim is denied, you have the right to appeal the decision. Follow the instructions provided on the denial letter.

5. Contact Medicare

Reach out to the Social Security Administration (SSA) at 1-800-MEDICARE (1-800-633-4227) for assistance with Medicare coverage.

Medicare Coverage Requirements

To qualify for Medicare coverage, your PAE must meet the following requirements:

Requirement	Description
Medical Necessity	A doctor must determine that a PAE is necessary to treat your respiratory condition.
Appropriate Use	The PAE must be used as prescribed by your doctor.
Durable Medical Equipment	The PAE must be durable and able to withstand repeated use.
Cost-Effective	Medicare must determine that the PAE is cost-effective in treating your condition.

Frequently Asked Questions

1. How long does Medicare coverage for a PAE last?

Medicare coverage typically lasts for the duration of your respiratory condition.

2. Can I use a PAE if I have a respiratory condition that is not listed in the Medicare coverage criteria?

In some cases, you may be able to get coverage for a PAE even if your condition is not specifically listed. You will need to talk to your doctor and Medicare to determine if you qualify.

3. Is there a deductible or coinsurance for PAE coverage?

The deductible and coinsurance for PAE coverage vary depending on your Medicare plan. Check with your insurance provider for specific details.

Is PAE Covered by Medicare Insurance?

Medicare Part B (Medical Insurance) covers most of the costs of medically necessary healthcare services, including physical therapy. This includes pulmonary artery embolism (PAE) treatment.

In general, Medicare covers PAE treatment if:

– It is ordered by a doctor and medically necessary.
– It is provided by a qualified physical therapist.
– It is part of a plan of care that is designed to improve your condition.

Recent Changes to Medicare Coverage for PAE

In 2020, Medicare made changes to its coverage for PAE treatment. These changes include:

– Medicare will now cover up to 36 sessions of physical therapy for PAE per calendar year. This is an increase from the previous limit of 24 sessions per calendar year.
– Medicare will now cover the cost of home health services for PAE if you are unable to leave your home. This includes physical therapy services.
– Medicare will now cover the cost of outpatient rehabilitation services for PAE. This includes physical therapy services.

These changes are designed to improve access to care for people with PAE.

What is PAE

A pulmonary artery embolism (PAE) is a blockage in one or more of the arteries in your lungs. This can cause serious health problems, including death.

Symptoms of a PAE can include:

– Chest pain
– Shortness of breath
– Rapid heart rate
– Lightheadedness or fainting
– Coughing up blood

If you experience any of these symptoms, it is important to see a doctor right away.

Treatment for PAE

Treatment for a PAE typically includes:

– Medications to dissolve the blood clot
– Surgery to remove the blood clot
– Physical therapy to help you regain function and mobility

Physical therapy for PAE can help you to:

– Improve your breathing
– Increase your range of motion
– Strengthen your muscles
– Decrease your pain
– Prevent future blood clots

| What is covered | What is not covered |
|—|—|
| Physical therapy | Physical therapy that is not medically necessary |
| Home health services | Home health services that are not medically necessary |
| Outpatient rehabilitation services | Outpatient rehabilitation services that are not medically necessary |

What is Medicare?

Medicare is a health insurance program for people 65 and older, younger people with certain disabilities, and people with end-stage renal disease.

Types of Medicare Coverage

Medicare consists of two parts: Part A and Part B.

Part A

Part A covers hospital stays, skilled nursing facility care, hospice care, and some home health care.

Part B

Part B covers doctor visits, outpatient care, durable medical equipment, and some preventive services.

The Benefits of Medicare Coverage for PAE

There are many benefits to having Medicare coverage for PAE. Some of the most important benefits include:

1. Financial Help

Medicare can help you pay for the costs of PAE. This can include the cost of the procedure itself, as well as the cost of related services, such as anesthesia and hospital care.

2. Access to Quality Care

Medicare covers care from a wide range of providers, including doctors, hospitals, and skilled nursing facilities. This means that you can get the care you need from the providers you trust.

3. Peace of Mind

Having Medicare coverage for PAE can give you peace of mind knowing that you have access to the care you need, when you need it.

4. Reduced Out-of-Pocket Costs

Medicare coverage can help you reduce your out-of-pocket costs for PAE. This is because Medicare covers a significant portion of the cost of the procedure.

5. Protection from Financial Ruin

PAE can be a very expensive procedure. Having Medicare coverage can help protect you from financial ruin if you need to have the procedure.

6. Increased Access to Care

Medicare coverage can help you increase your access to care. This is because Medicare covers a wider range of providers and services than most other health insurance plans.

7. Improved Health Outcomes

Medicare coverage can help you improve your health outcomes. This is because Medicare covers a wider range of preventive services and screenings than most other health insurance plans.

8. Reduced Stress

Having Medicare coverage for PAE can help reduce your stress. This is because you know that you have access to the care you need, when you need it.

9. Increased Independence

Medicare coverage can help you increase your independence. This is because Medicare covers a wide range of services that can help you live independently.

10. Improved Quality of Life

Medicare coverage for PAE can help you improve your quality of life. This is because Medicare covers a wide range of services that can help you live a healthier and more fulfilling life.

Medicare Coverage Requirements for PAE

In order to be covered by Medicare for PAE, you must meet certain requirements. These requirements include:

You must be enrolled in Medicare Part A and Part B.
You must have a doctor’s order for PAE.
The PAE must be performed by a qualified provider.
The PAE must be medically necessary.

Medicare Coverage for PAE: The Basics

Benefit	Part A	Part B
Hospital stay	Covered	Not covered
Skilled nursing facility care	Covered	Not covered
Home health care	Covered	Not covered
Doctor visits	Not covered	Covered
Outpatient care	Not covered	Covered
Durable medical equipment	Not covered	Covered
Preventive services	Not covered	Covered

Medicare Coverage for PAE: The Details

Medicare coverage for PAE is complex. There are many different rules and regulations that determine what is covered and what is not. If you are considering having PAE, it is important to talk to your doctor and your Medicare representative to learn more about your coverage options.

Here are some of the details of Medicare coverage for PAE:

Medicare Part A covers the cost of the hospital stay, skilled nursing facility care, and home health care related to the PAE.
Medicare Part B covers the cost of the doctor’s visits, outpatient care, durable medical equipment, and preventive services related to the PAE.
Medicare does not cover the cost of the PAE itself.
Medicare does not cover the cost of travel to and from the PAE.
Medicare does not cover the cost of food and lodging during the PAE.

Medicare Coverage for PAE: How to Get Help

If you need help understanding Medicare coverage for PAE, there are several resources available to you.

You can talk to your doctor or your Medicare representative.
You can call the Medicare helpline at 1-800-MEDICARE (1-800-633-4227).
You can visit the Medicare website at www.medicare.gov.

Medicare Coverage for PAE: Conclusion

Medicare coverage for PAE can be a valuable resource for people who need this procedure. Medicare can help you pay for the costs of PAE, access quality care, and reduce your out-of-pocket costs. If you are considering having PAE, it is important to talk to your doctor and your Medicare representative to learn more about your coverage options.

Medicare Coverage for PAE for Retirees

Medicare, the federal health insurance program for people aged 65 and older and certain younger people with disabilities, covers a wide range of medical services. One of these services is photoacoustic emission (PAE) therapy. PAE is a non-invasive treatment that uses sound waves to stimulate the body’s own healing processes.

Medicare Coverage for PAE

Medicare covers PAE treatment for a variety of conditions, including:

Arthritis
Back pain
Bursitis
Carpal tunnel syndrome
Chronic fatigue syndrome
Fibromyalgia
Headaches
Migraines
Muscle spasms
Neck pain
Osteoporosis
Plantar fasciitis
Sciatica
Tennis elbow
Tendonitis

Medicare Coverage for PAE for Retirees

Medicare covers PAE treatment for retirees who meet the following criteria:

They are enrolled in Medicare Part B (Medical Insurance).
They have a qualifying medical condition that is covered by Medicare.
Their doctor prescribes PAE treatment as medically necessary.
They receive PAE treatment from a qualified provider who accepts Medicare assignment.

Medicare Coverage for PAE for Retirees: Coverage Details

Medicare covers up to 80% of the approved cost of PAE treatment. The remaining 20% is the patient’s responsibility. Medicare does not cover the cost of the initial evaluation or the cost of any supplies or equipment needed for PAE treatment.

Medicare Coverage for PAE for Retirees: How to Get Coverage

To get Medicare coverage for PAE treatment, you will need to do the following:

See your doctor and get a referral for PAE treatment.
Find a qualified provider who accepts Medicare assignment.
Get a prescription for PAE treatment from your doctor.
Submit a claim to Medicare for reimbursement.

Medicare Coverage for PAE for Retirees: Other Considerations

There are a few other things to keep in mind about Medicare coverage for PAE treatment:

Medicare does not cover PAE treatment for cosmetic purposes.
Medicare does not cover PAE treatment that is experimental or investigational.
Medicare may deny coverage for PAE treatment if it is not medically necessary.

Medicare Coverage for PAE for Retirees: Frequently Asked Questions

What is the difference between PAE and other types of physical therapy? PAE is a non-invasive treatment that uses sound waves to stimulate the body’s own healing processes. Other types of physical therapy, such as massage and stretching, involve the use of manual techniques to improve range of motion and reduce pain.
Is PAE safe? Yes, PAE is a safe and effective treatment for a variety of conditions. There are no known side effects associated with PAE treatment.
How long does PAE treatment take? PAE treatment typically takes 6-12 weeks, with each session lasting 15-30 minutes. The number of sessions you need will depend on your condition and how well you respond to treatment.
How much does PAE treatment cost? The cost of PAE treatment varies depending on the number of sessions you need and the provider you see. However, Medicare covers up to 80% of the approved cost of PAE treatment.
Can I get PAE treatment if I have Medicare Advantage? Yes, you can get PAE treatment if you have Medicare Advantage. However, you may need to pay a higher deductible or coinsurance for PAE treatment. You should contact your Medicare Advantage plan to find out what your coverage is for PAE treatment.

Medicare Part	Coverage
Part A (Hospital Insurance)	Does not cover PAE
Part B (Medical Insurance)	Covers PAE for qualifying medical conditions
Part C (Medicare Advantage)	May cover PAE, but coverage may vary
Part D (Prescription Drug Coverage)	Does not cover PAE

Medicare Coverage for PAE for Children

Medicare coverage for posterior arthrodesis (PAE) for children depends on the child’s age, the underlying medical condition, and the specific procedure performed.

Medicare Part A Coverage

Medicare Part A covers inpatient hospital care, including PAE surgery, when it is deemed medically necessary. Inpatient hospital care means that the child is admitted to a hospital as an inpatient for at least 24 hours before the surgery is performed.

Medicare Part A also covers post-operative care in a skilled nursing facility (SNF) if the child meets certain criteria, such as needing skilled nursing care on a daily basis and being unable to perform basic activities of daily living.

Medicare Part B Coverage

Medicare Part B covers outpatient services, including PAE surgery, when it is deemed medically necessary. Outpatient services mean that the child is not admitted to a hospital as an inpatient for at least 24 hours after the surgery is performed.

Medicare Part B also covers certain follow-up care after PAE surgery, such as physical therapy and occupational therapy.

Limitations of Medicare Coverage

There are certain limitations to Medicare coverage for PAE for children. For example, Medicare Part A does not cover outpatient surgery, and Medicare Part B does not cover inpatient surgery.

Additionally, Medicare coverage for PAE may be limited by the child’s age. For example, Medicare Part A only covers inpatient hospital care for children under the age of 19, and Medicare Part B only covers outpatient services for children under the age of 22.

Qualifying for Medicare Coverage

In order to qualify for Medicare coverage for PAE, the child must have a qualifying medical condition and the surgery must be deemed medically necessary. Qualifying medical conditions for PAE include:

Cerebral palsy
Spina bifida
Clubfoot
Scoliosis
Kyphosis
Lordosis

The decision of whether or not PAE surgery is medically necessary is made by the child’s doctor. The doctor will consider the child’s age, underlying medical condition, and the specific procedure being performed.

How to Apply for Medicare Coverage

To apply for Medicare coverage for PAE, you will need to submit a claim to Medicare. You can submit a claim online, by mail, or through a Medicare-approved claims processor.

When you submit a claim, you will need to provide the following information:

The child’s name and Medicare number
The date of the surgery
The name of the hospital or outpatient facility where the surgery was performed
The type of surgery that was performed
The diagnosis code for the child’s medical condition

42 Questions and Answers

Question: How much does Medicare pay for PAE surgery?

The amount that Medicare pays for PAE surgery depends on a number of factors, including the type of surgery performed, the length of the hospital stay, and the child’s age.

In general, Medicare Part A pays for 100% of the inpatient hospital care costs for children under the age of 19. Medicare Part B pays for 80% of the outpatient surgery costs for children under the age of 22.

The child’s Medicare deductible and coinsurance may also apply to the cost of PAE surgery.

Question: What is the recovery time for PAE surgery?

The recovery time for PAE surgery varies depending on the type of surgery performed and the child’s age.

In general, children can expect to be in a cast or brace for several months after surgery. They may also need to use crutches or a walker for a period of time.

Physical therapy and occupational therapy can help children regain strength and mobility after PAE surgery.

Question: What are the risks of PAE surgery?

The risks of PAE surgery include:

Bleeding
Infection
Blood clots
Nerve damage
Failure of the surgery to correct the deformity

The risks of PAE surgery are relatively low, but they should be discussed with the child’s doctor before surgery is performed.

Question: What are the benefits of PAE surgery?

The benefits of PAE surgery include:

Correcting the deformity
Improving the child’s mobility
Reducing pain
Improving the child’s overall quality of life

PAE surgery can be a life-changing procedure for children with severe deformities.

Question: What are the alternatives to PAE surgery?

The alternatives to PAE surgery include:

Bracing
Physical therapy
Occupational therapy
Medication

These treatments may be able to improve the child’s symptoms, but they may not be able to correct the deformity.

Question: How can I find a doctor who performs PAE surgery?

You can find a doctor who performs PAE surgery by asking your child’s pediatrician or by searching online.

When you are looking for a doctor, it is important to find someone who is experienced in performing PAE surgery on children.

Age	Medicare Coverage
Under 19	Medicare Part A covers inpatient hospital care
Under 22	Medicare Part B covers outpatient services

Medicare Coverage for PAE for Pregnant Women

What is Perianesthetic Evaluation (PAE)?

A perianesthetic evaluation (PAE) is a preoperative assessment of a pregnant woman’s medical history, current health, and obstetrical risk factors conducted by an anesthesiologist or certified registered nurse anesthetist (CRNA).

Why is a PAE Important?

A PAE helps identify and manage potential anesthesia-related risks during labor and delivery, ensuring the safety of both the mother and the baby.

Medicare Coverage for PAE

Medicare provides coverage for PAE for pregnant women under Part B of Original Medicare.

Eligible Conditions

To qualify for Medicare coverage, the PAE must be medically necessary and performed for a pregnant woman with:

A high-risk pregnancy
A history of previous anesthetic complications
Severe preeclampsia or eclampsia
Placenta previa or abruption
Multiple gestation (e.g., twins, triplets)

Services Covered

Medicare Part B covers the following services included in a PAE:

Service
Patient Interview and History
Physical examination
Assessment of obstetrical risk factors
Laboratory tests (e.g., blood count, coagulation studies)
EKG, if indicated
Anesthesia plan development

Coverage Exclusions

Medicare does not cover PAE if it is performed:

For a non-medically necessary reason
By a provider who is not an anesthesiologist or CRNA
Outside of a hospital or ambulatory surgical center

Cost-Sharing

The cost-sharing for a PAE covered by Medicare Part B may include:

Deductible
Coinsurance (20% of the Medicare-approved amount)
Excess charges (if the provider bills more than the Medicare-approved amount)

How to Get Covered

To receive Medicare coverage for a PAE, the following steps are required:

Obtain a referral from your primary care provider or obstetrician.
Schedule an appointment with an anesthesiologist or CRNA for a PAE.
Bring your Medicare card and any relevant medical records to the appointment.
The anesthesiologist or CRNA will perform the PAE and submit a claim to Medicare.

Medicare Coverage for PAE for Individuals with ALS

Medicare provides coverage for palatal augmentation epiglottoplasty (PAE) for individuals with amyotrophic lateral sclerosis (ALS) who meet specific criteria. This article discusses the Medicare coverage guidelines for PAE, the benefits of the procedure, and the process for obtaining coverage.

Medicare Coverage Criteria

Medicare covers PAE for individuals with ALS who have:

Progressive bulbar weakness, which leads to difficulty swallowing
Aspiration pneumonia, which is a serious infection of the lungs caused by inhaling food, liquid, or saliva
A tracheostomy tube that is not adequately preventing aspiration

Benefits of PAE

PAE is a surgical procedure that can improve swallowing function and reduce the risk of aspiration pneumonia in individuals with ALS. The procedure involves using a piece of the patient’s own tissue to create a new palate and epiglottis, which helps to prevent food and liquid from entering the lungs.

Benefits of PAE include:

Improved swallowing function
Reduced risk of aspiration pneumonia
Improved quality of life

Process for Obtaining Coverage

To obtain Medicare coverage for PAE, individuals must meet the following requirements:

Be diagnosed with ALS by a neurologist
Have documentation of progressive bulbar weakness and aspiration pneumonia
Obtain a referral from a neurologist or pulmonologist to a surgeon who performs PAE
Submit a Medicare claim form along with medical documentation to support the need for PAE

Medicare Part A Coverage

Medicare Part A covers the cost of PAE as an inpatient procedure in a hospital or skilled nursing facility. Coverage includes the surgery itself, anesthesia, and hospital care.

Medicare Part B Coverage

Medicare Part B covers the cost of PAE as an outpatient procedure in a doctor’s office or clinic. Coverage includes the surgeon’s fee, anesthesia, and other related expenses.

Out-of-Pocket Costs

Individuals may have out-of-pocket costs for PAE, such as:

Deductible
Coinsurance
Copayments

The amount of out-of-pocket costs will vary depending on the individual’s Medicare coverage plan.

Additional Information

Here are some additional things to consider about Medicare coverage for PAE:


Does Medicare cover temporary PAE?	Yes, Medicare covers temporary PAE for up to 6 months.
Does Medicare cover permanent PAE?	Yes, Medicare covers permanent PAE after a temporary PAE has been successful.
Is there a waiting period for Medicare coverage?	No, there is no waiting period for Medicare coverage of PAE.
How long does it take to get Medicare approval for PAE?	Medicare typically approves PAE requests within 30 days.

Is PAE Covered by Medicare Insurance?

Medicare is a health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD). Medicare Part A covers hospital stays, skilled nursing facility care, hospice care, and some home health care. Medicare Part B covers medically necessary doctor services, outpatient care, medical supplies, and durable medical equipment.

Percutaneous Atrial Septostomy (PAE) is a procedure that creates an opening (septal defect) in the wall (septum) that divides the upper chambers of the heart (atria). This opening allows blood to flow from the right atrium to the left atrium, increasing blood flow to the lungs and improving oxygen levels in the blood. PAE is typically performed in people with severe heart failure who are not candidates for open-heart surgery.

Medicare Part A covers the cost of PAE if it is performed in a hospital setting. Medicare Part B covers the cost of PAE if it is performed in a doctor’s office or an outpatient clinic.