As medical science continues to push boundaries, innovative treatments like stem cell therapy hold immense promise for regenerative medicine and addressing various health conditions. However, there’s one big problem. Stem cell therapy is very expensive. Fortunately, Medicare does provide coverage for stem cell therapy if certain conditions are met. Keep reading to learn more about Medicare’s coverage for stem cell therapy including specific eligibility requirements.

What Is Stem Cell Therapy?

Stem cell therapy, also known as regenerative medicine, is a treatment that introduces new cells into damaged tissue to treat disease or injury. These cells are unique as they can develop into many different cell types, which gives them the potential to repair diseased or damaged tissues in the body.

Stem cells are derived from two primary sources: embryonic stem cells and adult stem cells. Embryonic stem cells are obtained from embryos, whereas adult stem cells are procured from adult tissues. There’s also a third category, induced pluripotent stem cells (iPSCs), which are adult cells genetically reprogrammed to act like embryonic stem cells.

Stem cell therapy is being explored and developed to treat a broad spectrum of conditions. This includes diseases like heart disease, Parkinson’s disease, and diabetes, as well as injuries such as burns and spinal cord damage. Certain types of cancer, like leukemia and lymphoma, can be treated using stem cell transplants, specifically bone marrow transplants.

This field is still expanding and evolving, and researchers believe stem cell therapy holds the key to treating many other conditions. These include neurodegenerative diseases like Alzheimer’s and even autoimmune diseases like lupus.

Despite their immense potential, stem cell therapies also present certain challenges and ethical considerations. The extraction, storage, and use of these cells, particularly embryonic stem cells, are topics of ongoing discussion and regulation within the scientific community.

How Much Does Stem Cell Therapy Cost?

When it comes to the cost of stem cell therapy, it doesn’t come cheap. This is primarily due to the complexity of the process involved in harvesting, storing, and administering stem cells. Also, the treatment’s cutting-edge nature, combined with the high level of expertise needed to carry it out, adds to the cost.

The cost varies significantly depending on the type of stem cell therapy you need, the specific medical condition being treated, and where you’re receiving the treatment. Stem cell therapy can range from $5,000 to more than $25,000 per treatment session. For example, treatment for orthopedic conditions using stem cells can cost between $5,000 and $10,000, while treatments for more severe conditions like multiple sclerosis can climb up to $25,000 or more.

Remember, these costs are typically per session, and some conditions may require multiple sessions, which means the total cost can quickly escalate. Plus, these costs may not include related expenses such as diagnostic tests, hospital stays, and follow-up care. These additional costs can add thousands more to the total price.

While insurance, including Medicare, can help with some of these costs, it’s crucial to note that coverage for stem cell therapy varies widely. Some treatments may be fully covered, others partially, and still others may not be covered at all. That’s why it’s essential to fully understand the extent of your Medicare coverage when considering stem cell therapy.

Medicare Coverage For Stem Cell Therapy

Medicare covers stem cell therapy if you meet the eligibility requirements. The first requirement is medical necessity. That simply means the stem cell therapy must be considered necessary by your healthcare provider for treating your specific condition.

In addition, the stem cell therapy must be approved by the Food and Drug Administration (FDA). The FDA plays a vital role in ensuring that the medications and treatments available to patients are safe and effective. Therefore, Medicare coverage typically extends only to those stem cell therapies that have been validated and approved by the FDA.

When it comes to the specifics of what parts of Medicare cover what costs, Medicare Part A and Part B come into play. Medicare Part A, also known as hospital insurance, covers inpatient hospital stays. So if your stem cell therapy requires you to be admitted to the hospital, Part A will provide coverage.

On the other hand, Medicare Part B covers outpatient costs. This includes medical services like doctor’s visits, diagnostic tests, and outpatient treatments, including some stem cell therapies. So, if your stem cell treatment doesn’t require hospital admission and is carried out in an outpatient setting, it’s Part B that would typically cover a portion of the costs.

It’s important to remember that coverage details can vary based on your specific circumstances and the details of your Medicare plan. Always consult with your healthcare provider and your Medicare plan to confirm what coverage you have for stem cell therapy.

What Stem Cell Therapies Are Covered?

While Medicare does not universally cover all types of stem cell therapies, it does cover certain treatments that are considered standard care or have proven effectiveness in clinical trials. Here are the Medicare-approved stem cell therapies:  

Hematopoietic Stem Cell Transplantation (HSCT)

Hematopoietic Stem Cell Transplantation (HSCT) is a treatment often used to help patients with certain types of cancers such as leukemia, lymphoma, and multiple myeloma. HSCT involves using chemotherapy or radiation therapy to destroy the patient’s existing bone marrow, which might be producing abnormal cells. Then, healthy hematopoietic (blood-forming) stem cells are transplanted into the patient to rebuild the bone marrow and blood cells.

These stem cells can be harvested from the patient’s own body (autologous transplant) or from a donor (allogeneic transplant). Medicare typically covers HSCT when it’s used for Medicare-approved conditions, which include certain types of cancers and severe aplastic anemia, among others.

Autologous Stem Cell Transplantation (AuSCT)

Autologous Stem Cell Transplantation (AuSCT) is a specific type of HSCT where the stem cells used for the transplant are collected from the patient’s own body. The collected stem cells are stored and later reintroduced into the patient after they have undergone intensive treatment like high-dose chemotherapy or radiation therapy to destroy the diseased cells.

This procedure is commonly used in the treatment of certain cancers, including lymphomas and multiple myeloma, where high-dose treatments aim to eradicate cancer cells, and the reintroduced stem cells help to restore the bone marrow. As with HSCT, Medicare typically covers AuSCT for specific conditions, predominantly certain types of cancers.

Remember, while these therapies are typically covered, Medicare coverage can vary based on individual circumstances, and approval may depend on factors such as your overall health, the stage of your disease, and other treatments you’ve tried. Always consult with your healthcare provider and a licensed Medicare agent to ensure you understand your coverage. For more information, please call 866-MEDIGAP (866-633-4427).

Does Medicare Advantage Cover Stem Cell Therapy?

Medicare Advantage, also known as Medicare Part C, is an alternative to traditional Medicare that offers the same benefits as Medicare Parts A and B, but it’s provided by private insurance companies. Many people choose Medicare Advantage because it often provides additional benefits, like prescription drug coverage, vision, dental, and wellness programs, that aren’t included in original Medicare.

Medicare Advantage plans are required by law to cover everything that original Medicare covers, which includes certain stem cell therapies like Hematopoietic Stem Cell Transplantation (HSCT) and Autologous Stem Cell Transplantation (AuSCT) that are deemed medically necessary and approved by the FDA.

However, because Medicare Advantage plans are administered by private insurance companies, they can choose to cover additional services that original Medicare does not. This means some Medicare Advantage plans might offer broader coverage for stem cell therapies than original Medicare.

It’s also important to note that the specifics of what each Medicare Advantage plan covers and the amount you pay out-of-pocket can vary widely between plans and insurance providers. That’s why it’s highly recommended to speak with a licensed agent if you’re considering stem cell therapy.

Lastly, just like with original Medicare, even if a stem cell therapy is covered, you’ll typically still be responsible for certain costs. These can include your plan’s deductibles, copayments, and coinsurance. Therefore, it’s important to understand these costs upfront so you can plan your budget accordingly.

Does Medicare Supplement Cover Stem Cell Therapy?

Medicare Supplement insurance, often referred to as Medigap, is a type of insurance policy that helps cover the “gaps” in Original Medicare coverage. These gaps refer to out-of-pocket costs like deductibles, copayments, and coinsurance. Medigap policies are sold by private insurance companies and are meant to work alongside your Original Medicare coverage.

Medicare does cover certain stem cell therapies such as Hematopoietic Stem Cell Transplantation (HSCT) and Autologous Stem Cell Transplantation (AuSCT) when they are deemed medically necessary and approved by the FDA. If you have a Medigap policy and you undergo one of these covered stem cell therapies, your policy may help with the deductibles, coinsurance, or copayments associated with the treatment.

However, if the stem cell therapy you’re considering is not covered by Original Medicare, your Medigap policy will not provide coverage either. Medigap coverage mirrors Original Medicare’s coverage. Therefore, if a service or treatment is not covered by Original Medicare, Medigap won’t cover it.

Remember, the specifics of what each Medigap policy covers can vary, and not all policies cover the same out-of-pocket costs. Always review your Medigap policy’s coverage before undergoing any medical procedure. If you’re considering stem cell therapy or have questions about your Medigap coverage, it’s highly advised to speak with a licensed agent specializing in Medicare.

Conclusion

Medicare does cover certain stem cell treatments like Hematopoietic Stem Cell Transplantation (HSCT) and Autologous Stem Cell Transplantation (AuSCT), but only in specific situations. Your Medicare Part A plan helps with the costs of inpatient procedures, while Part B assists with outpatient procedures.

Stem cell therapy is always changing and evolving. Because of this, coverage may also change over time. That’s why it’s important to talk to your healthcare provider and a licensed agent about your Medicare plan to fully understand what stem cell treatments they will cover. That way you don’t end up with any unnecessary out-of-pocket expenses later.

Please don’t hesitate to reach out to us at 866-MEDIGAP (866-633-4427) if you have any questions about Medicare coverage for stem cell therapy. We’ll be happy to review your current plan and recommend any additional coverage that would be beneficial to help with the costs of stem cell therapy treatments. So, give us a call today. We look forward to speaking with you!