Medicare Coverage for Axonics Therapy: What You Should Know

Living with bladder or bowel control issues can be emotionally and physically draining. For many people struggling with overactive bladder (OAB), fecal incontinence, or urinary retention, Axonics Therapy shows a promising solution. However, with any medical treatment, especially advanced therapies, a critical question arises: Is Axonics therapy covered by Medicare?

This blog provides an in-depth look at everything you need to know about Axonics Therapy and its place within Medicare coverage. We’ll break down costs, coverage differences between Original Medicare and Medicare Advantage, and what to expect in terms of authorizations, out-of-pocket costs, and real patient experiences.

Is Axonics Therapy Covered by Medicare?

Yes, Axonics Therapy is covered by Medicare under certain conditions. It is classified as a sacral neuromodulation therapy, which is FDA-approved for treating overactive bladder, fecal incontinence, and urinary retention. Medicare typically covers Axonics as a medically necessary treatment, but it must be prescribed by a Medicare-participating physician and meet specific clinical criteria.

Coverage may include the test stimulation phase (trial) and, if successful, the long-term implant. However, approval is not automatic. Patients must demonstrate that more conservative treatments have failed, such as behavioral therapy or medication.

If you’re wondering, is Axonics therapy covered by Medicare in your specific case, it’s best to consult with your provider and verify coverage based on your Medicare plan type and medical history.

How Much Does Axonics Therapy Cost with Medicare?

The total cost of Axonics Therapy can vary, but it normally ranges from $20,000 to $30,000 for the device and surgical procedure combined. With Original Medicare, beneficiaries are liable for 20% of the Medicare-approved amount after meeting their Part B deductible.

However, coverage is split into stages:

• Trial phase: Covered under Medicare Part B as an outpatient procedure
• Implant phase: Can be covered under Part B (outpatient) or Part A (inpatient), depending on the setting

A Medigap (Medicare Supplement) plan can help cover the remaining 20% coinsurance if you have one. Always check with your healthcare provider’s billing office for a detailed breakdown.

Do Medicare Advantage Plans Cover Axonics Therapy?

Medicare Advantage (Part C) plans are required to provide the same benefits as Original Medicare. Still, they may have different rules about access and cost-sharing. Many Medicare Advantage plans do cover Axonics Therapy, but the coverage depends on the plan’s network, preauthorization policies, and formularies.

The key difference is that Medicare Advantage plans usually require prior authorization, even for medically necessary treatments. Coverage may also be restricted to in-network specialists or specific surgical facilities.

If you’re enrolled in a Medicare Advantage plan, confirm with your carrier if Axonics therapy is covered by Medicare Advantage and whether you need a referral or pre-approval.

What Are the Medicare Requirements for Axonics Therapy Coverage?

Medicare coverage for Axonics Therapy generally includes the following requirements:

• A diagnosis of OAB, fecal incontinence, or urinary retention that has not improved with conservative treatments
• Documentation of failed first-line therapies, such as pelvic floor exercises, bladder training, or medications
• A successful trial stimulation phase that shows measurable improvement in symptoms
• A Medicare-enrolled provider who performs the therapy and complies with CMS billing guidelines

These criteria are used to determine medical necessity. Your doctor will submit documentation and medical records to demonstrate you meet the requirements.

How Do You Get Prior Authorization for Axonics Therapy with Medicare?

Original Medicare generally does not require prior authorization for Axonics Therapy. However, Medicare Advantage plans do. To get prior authorization:

1. Your healthcare provider must submit medical documentation justifying the need for Axonics.
2. This includes your history of symptoms, past treatment attempts, and expected benefits from the procedure.
3. Once submitted, the plan will review the request, which may take a few days to several weeks.
4. You and your provider will obtain written confirmation of approval or denial.

If denied, you have the right to appeal the decision. Work closely with your provider to strengthen the case if needed.

Are There Out-of-Pocket Costs for Axonics Therapy with Medicare?

• 20% coinsurance with Original Medicare (Part B), unless you have Medigap
• Copays, coinsurance, or deductibles under a Medicare Advantage plan, depending on the policy
• Additional costs if you use out-of-network providers or services that are not fully approved

Costs can also vary based on whether the trial and implantation are performed in outpatient settings, surgical centers, or hospitals. It’s important to get a cost estimate from your provider in advance.

Can You Get Reimbursed for Axonics Therapy Through Medicare?

If you paid for any part of the procedure out of pocket and believe it should have been covered, you may request reimbursement. To do so:

• Ask your provider for a Medicare Summary Notice (MSN) or Explanation of Benefits (EOB)
• Submit a reimbursement claim to Medicare or your Medicare Advantage plan
• Include proof of payment and a detailed bill
• Keep all documents for your records

Reimbursement is more likely when the treatment meets all medical necessity criteria and is performed by a Medicare-enrolled provider.

What’s the Difference Between Medicare and Private Insurance Coverage for Axonics Therapy?

The core distinction lies in authorization processes, cost-sharing, and network flexibility:

• Private insurance plans may offer broader or more restrictive coverage depending on the employer or carrier
• Medicare tends to have standardized criteria and presents consistent coverage once medical necessity is confirmed
• Medicare Advantage operates like private insurance and adds variability in prior authorization, cost, and provider choice

In some cases, private insurers may be more restrictive or may not cover Axonics Therapy at all. That makes Medicare a preferred option for eligible seniors dealing with chronic bladder or bowel issues.

What Are Patient Experiences with Axonics Coverage Under Medicare?

Patients have reported positive outcomes with Axonics Therapy and a relatively smooth coverage process through Medicare, especially when they work with experienced urologists or urogynecologists familiar with Medicare documentation requirements.

Many have noted that:

• The trial phase helped them decide confidently before the full implant
• Medigap plans eased the financial burden of coinsurance
• Pre-approval under Medicare Advantage required more paperwork but was achievable with physician support

However, there are occasional frustrations with:

• Delays in prior authorization under Medicare Advantage plans
• Unexpected costs due to billing errors or out-of-network facilities

That’s why choosing a Medicare-participating specialist and staying proactive with your plan

can make a big difference.

Conclusion

Axonics Therapy can be life-changing for those dealing with incontinence or urinary retention, and Medicare does provide coverage in most medically necessary cases. The key is to understand the stages involved, including trial approval, provider selection, prior authorization (if needed), and potential out-of-pocket costs.

If you’re still asking, is Axonics therapy covered by Medicare, the answer is yes, but coverage varies based on plan type, provider, and your specific medical history. Be sure to consult with a licensed Medicare agent or speak with your doctor to get a personalized breakdown of your options.

Disclaimer: This article is for informational purposes only. Medicare coverage and costs can vary by region, plan type, and individual circumstances. Always speak directly with your provider or Medicare representative for the most accurate information.

Source: healthcare.gov