Transcript (Kidney Stones and Medicare)

Introduction

Kidney stones are small, pebble-like deposits in the urinary tract. They can be tiny, but the pain can feel huge. Kidney stones are common, especially among men and people 60 and older. The lifetime risk of developing kidney stones is 11% for men, compared to 6% for women. Common types of kidney stones include Calcium stones [most common], Uric acid stones, Struvite and Cystine stones.

Medicare can help with prevention, diagnosis, treatment, recovery, and medications. Before we get into coverage for kidney stones, it helps to look at what Medicare covers overall. Part A covers medically necessary inpatient hospital stays and skilled nursing facility care. It also covers hospice and some home health services. Part B includes doctor visits, preventive services, durable medical equipment, and outpatient care. Part D generally covers prescription drugs you get from a pharmacy.

Medicare A, B, and D can include co-insurance, co-pays, and deductibles.

In this video, we’ll walk through kidney stone prevention, diagnosis, treatment, rehabilitation, and medications.

Prevention and Screening

Kidney stone prevention is not one-size-fits-all. Risk factors include dehydration, family history, high sodium intake, diabetes, and urinary infections. Medicare does not usually cover routine kidney stone screening. Medicare Part B covers most preventive services, including a Yearly Wellness visit. Those visits may support a kidney stone prevention plan.

Diagnosis

Diagnosis usually starts with symptoms and a medical history. Your doctor may ask about pain, urine changes, and medications. Medicare Part B covers medically necessary doctor visits, urine tests, imaging, and blood tests, subject to a deductible and 20% coinsurance.

Testing can detect urine crystals, kidney function, and infections. Medicare covered imaging may include a CT scan, ultrasound, or X-ray.

Treatment

Treatment depends on the stone’s size and location. It also depends on pain, infection, and kidney function. Some stones may pass with monitoring and medication.

If medically necessary, Medicare covers these common procedures, including shock wave lithotripsy, ureteroscopy with laser lithotripsy, ureteral stent placement, and percutaneous nephrolithotomy.

Medicare coverage for inpatient stays begins after you meet the Part A deductible.

The Part A deductible applies per benefit period, not just once each year.

Medicare Part B may cover outpatient care for kidney stones, including doctor visits, urgent care, ER visits, lab work, imaging, and some durable medical equipment.

Recovery and Follow-up

Medicare covers medically necessary follow-up care. Recovery depends on whether the kidney stone passed naturally or required a procedure.

Your doctor may check for infection or confirm the stone is gone by checking kidney function, lab tests, or repeat imaging. Follow-up may include stent removal.

Medicare may cover therapy, home health, or skilled nursing facility care when eligibility rules are met. Part A applies to skilled nursing facilities when certain criteria are met. Skilled nursing care typically requires a three-day inpatient hospital stay first.

Medications

Medicare Part D usually covers prescriptions obtained at a pharmacy. Kidney stone drugs can include pain relievers, anti-nausea meds, antibiotics, and alpha blockers. Prevention medications include thiazide diuretics, potassium citrate, or allopurinol.

Prescription drug coverage varies by plan rules, tiers, formulary, and pharmacy network. A formulary is a drug list covered by your Part D plan. A drug may require prior authorization, step therapy and quantity limits. Part B often covers drugs given in medical settings. In most cases, this involves drugs given via injection or infusion, and vaccines for prevention.

Medicare Advantage Considerations

With Medicare Advantage, additional rules come into play. All plans must include Medicare services; however, the guidelines can change. Network use, referrals, and prior authorization may affect access. Medicare Advantage plan rules can also affect costs and timing.

Final Thoughts

Kidney stones can be painful, but Medicare covered treatment is available. Medicare may help cover testing, treatment, follow-up, and medications. But coverage depends on medical necessity and the care setting. Peace of mind comes from self-awareness and action.