Medicare Coverage for Stem Cell Therapy

Does Medicare cover stem cell therapy?

Medicare covers stem cell therapy for FDA-approved treatments, which are typically for hematopoietic stem cell transplants. These are stem cell therapies that promote the growth of healthy blood cells.

These therapies are sometimes used to treat certain cancers, including:

  • lymphomas
  • acute myeloid leukemia
  • Waldenstrom macroglobulinemia
  • testicular germ cell cancer

These therapies can also help treat sickle cell disease.

Medicare Part A

Medicare Part A is the inpatient portion of Medicare and covers hospital services and some skilled nursing care. When in the hospital, you may need stem cell therapy to treat your condition.

If your doctor has admitted you as an inpatient, Medicare Part A may cover this treatment.

Once you’ve paid the Medicare deductible for Part A, Medicare will cover the remaining portion of the inpatient costs for up to a 60-day stay. The Part A deductible for 2021 is $1,484.

Medicare Part B

Medicare Part B covers outpatient procedures, which include some instances of stem cell therapy.

A doctor must declare that your stem cell treatment is medically necessary, and once you’ve met your Medicare Part B deductible, you’ll pay 20 percent of the Medicare-approved amount for stem cell therapy. The Part B deductible is $203 for 2021.

Medicare Advantage

Medicare Advantage plans, also known as Medicare Part C, cover the same components as original Medicare. Plans may also offer expanded coverage, including prescription drugs.

Medicare Advantage will cover the same stem cell treatments as original Medicare.

Medigap

Medigap, or Medicare supplement, plans can help reduce out-of-pocket costs related to Medicare expenses. Medicare standardizes these plans, and you can choose one that meets your coverage needs.

Medigap could also potentially help pay costs for your Part A or Part B coinsurance or a portion of the Part A deductible.

Whether Medigap covers stem cell costs depends on your policy and the way you’re charged. You can call your plan provider to confirm whether treatment will be covered.

Which stem cell therapies are covered?

Medicare covers two types of stem cell transplants: allogeneic stem cell transplantation and autologous stem cell transplantation.

While researchers are studying many other stem cell therapy approaches, the only current FDA-approved treatments are for:

  • cancers
  • blood disorders
  • immune system disorders

The following sections provide more details regarding the different types of stem cell therapies.

Allogenic stem cell transplantation

This approach involves taking a healthy donor’s stem cells and preparing them for intravenous infusion.

This therapy would be used if you have an underlying condition that affects your ability to create new blood cells. This is called an allogeneic transplant.

Conditions this approach may treat include:

  • myelofibrosis
  • leukemia
  • Wiskott-Aldrich syndrome
  • sickle cell disease
Autologous stem cell transplantation

This approach involves using your own previously stored stem cells. This treatment may be recommended if you have cancer and require chemotherapy or radiation that may destroy blood-producing cells.

Examples of such conditions include:

  • non-Hodgkin’s lymphoma
  • recurrent neuroblastoma
  • amyloidosis

How much does stem cell therapy cost?

It’s important to know that stem cell therapies are still very expensive. A doctor may recommend different regimens based on your overall health, which are done in an inpatient setting and increases overall costs.

In a 2017 study of 1,562 inpatients who received hematopoietic stem cell transplantation, the average costs were:

  • $289,283 for a myeloablative allogeneic treatment regimen with an average inpatient stay of 35.6 days
  • $253,467 for a non-myeloablative/reduced-intensity allogeneic regimen with an average inpatient stay of 26.6 days
  • $140,792 for a myeloablative autologous regimen with an average inpatient stay of 21.8 days

These cost estimates are based on claims to private insurance companies, not Medicare. Costs could be different based on:

  • treatment types
  • your overall health
  • the costs negotiated between Medicare and health professionals each year

Remember that Medicare won’t cover costs that don’t meet its current standards for coverage. Covered treatments must be FDA approved and deemed medically necessary by your doctor.

Because stem cell injections can be so expensive, you can take some steps before the treatment to make sure you can afford them.

  • Ask your doctor for an estimate of treatment costs, including the doctor’s fees and materials costs for the injection.
  • Contact Medicare or your Medicare Advantage plan administrator to get an estimate for how much Medicare will cover.
  • Consider Medicare supplement plans (if applicable), which can help cover some of the out-of-pocket costs. Medicare Advantage plans may also be another avenue to explore, since some may have out-of-pocket spending limits.

What is stem cell therapy?

For more than 50 years, doctors have injected hematopoietic stem cells into the body to promote the growth of new blood cells. However, other approaches are now being studied as well.

According to the National Institutes of Health, stem cell research is done on embryonic stem cells or somatic (“adult”) stem cells.

Embryonic stem cells

Embryonic stem cells come from embryos created in a lab through in vitro fertilization. These cells come from donors for research purposes.

Embryonic stem cells are like a blank slate for the body’s cells. They can then differentiate, meaning they can become a blood cell or a liver cell or many other cell types in the body.

Somatic stem cells

Learn more

Somatic stem cells (adult stem cells) usually come from bone marrow, the bloodstream, or umbilical cord blood. These types of stem cells are different from embryonic stem cells because they can only become blood cells.

Stem cell delivery

Stem cell delivery is a multistep process that usually involves:

  • “conditioning” or high-dose chemotherapy or radiation to kill the cancerous cells and make room for the new stem cells
  • medication to suppress the immune system (if the stem cells come from another person) to reduce the chances of the body rejecting the stem cells
  • infusion through a central venous catheter
  • close monitoring during infusion and in the following days to reduce the risks for infections and stem cell rejection

Will Medicare cover stem cell therapy for knee treatment?

Researchers have studied the possibility of injecting stem cells into cartilage and other damaged tissue to reduce the effects of knee osteoarthritis.

According to a 2020 journal article, encouraging results have been seen in clinical trials. However, data is limited, and clinics may use different approaches to deliver the stem cells.

Other 2020 research found that stem cell therapy for knee arthritis was better than traditional conservative treatments, including taking anti-inflammatory medications.

Studies on stem cell therapy are ongoing and have not yet shown clear evidence that it will be helpful in treating knee osteoarthritis.

Medicare requires significant research and FDA approval to cover treatments. Because the use of stem cells to treat knee arthritis is a relatively new therapy, Medicare doesn’t cover the costs of these treatments.

Other options for treating knee arthritis

While Medicare may not currently cover stem cell therapy for knee arthritis, there are other treatments Medicare does usually cover if your doctor says treatment is medically necessary.

Covered treatments include:

  • physical therapy
  • nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen sodium
  • corticosteroid injections
  • hyaluronic acid injections, which are to lubricate the knee joint to reduce pain
  • nerve blocks
  • Voltaren Arthritis Pain, a topical gel available over the counter

Medicare may also cover surgical approaches to treating knee pain if these conservative treatments fail. Types of surgery include knee replacement.

The bottom line

Medicare currently covers stem cell therapy only for hematopoietic transplants. This therapy is used to treat blood-related cancers and other blood conditions like sickle cell disease.

Like many other cancer treatments, stem cell approaches are costly. It’s important to ask for an explanation and estimate of costs, including those covered and not covered by your Medicare plan.

You can then consider the costs versus the benefits when deciding if treatment is right for you.

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