With over 65 million Americans relying on Medicare, whether or not this program covers HIFU is important for those considering this treatment. 

Unfortunately, standard Medicare plans restrict coverage of HIFU treatment at the moment. The only approved use is for alleviating tremors associated with Parkinson’s disease. Using HIFU to treat tumors and cancer, including prostate cancer, isn’t on their list of covered conditions.

It’s a change that happened in recent years. Medicare used to reimburse healthcare facilities for HIFU treatment related to prostate cancer more broadly. But a shift in policies withdrew that coverage for now.

Patients who want to pursue HIFU as an option for treating prostate cancer need to be prepared to handle the costs out-of-pocket in most cases. At least until Medicare policy catches up with the latest medical research showing HIFU’s potential.

Does Medicare Advantage cover HIFU & how does it compare to Original Medicare?

Unlike Original Medicare, some Medicare Advantage plans provide a bit of coverage for HIFU. But there are still some limitations. 

Very few Medicare Advantage plans cover HIFU, and even then, usually only at certain approved hospitals they work with. Members still have to pay out-of-pocket for HIFU with Medicare Advantage too. 

You’ll have to carefully read all HIFU-related guidelines and rules of your Advantage plan – check what you’ll still owe and where you can get the treatment.

Who is eligible for Medicare-covered HIFU under CED?

CED (Coverage with Evidence Development) is a Medicare provision that allows conditional coverage for promising treatments while additional data is gathered. 

For HIFU prostate cancer therapy, coverage under CED means patients can potentially get Medicare assistance with costs if enrolled in an approved clinical trial. 

This allows Medicare beneficiaries access to this innovative treatment option while requiring continued research on safety and efficacy.

Under CED, Medicare lays out eligibility criteria that prostate cancer patients must meet to have HIFU treatment potentially covered. These main requirements are:

• 1. You must have biopsy-proven, organ-confined prostate cancer. Medicare defines organ-confined disease as clinical stage T1 or T2.
• 2. If you have intermediate or high-risk disease, you must have an accepted life expectancy of at least ten years to be covered. Studies suggest that lower-risk patients have better HIFU outcomes.
• 3. You must enroll as a participant in an approved clinical research study, like the TARGET-HIFU Registry Trial. The clinical study will track data related to your treatment experience, side effects, cancer control, and more.

What is the cost of HIFU treatment?

With no standardized rates across treatment centers, HIFU Medicare costs fall roughly between $8,000-$13,300.

Prices vary based on factors like these:

• Geographic location of the facility
• Hospital or private clinic setting
• Surgeon experience level
• Length/complexity of required treatment
• Follow-up consultation/testing requirements

Those able to utilize Medicare Advantage coverage may pay closer to $8,850 out-of-pocket as in-network maximum. This could go as high as $13,300 as an out-of-network maximum. 

The deductible for Medicare Part B in 2024 is $240. Meanwhile, the deductible for Medicare Part A is $1,632 .

While HIFU availability expands as more facilities invest in the technology, check back for potential Medicare policy changes in the coming years. Over time, coverage allowances for HIFU prostate cancer therapy may increase.

Conclusion 

While HIFU covered by Medicare doesn’t cover 100% of cancer care costs, coverage makes a big difference. 

And when it comes to innovative treatments like HIFU for prostate cancer, Medicare is stepping up to provide at least some coverage for patients. 

Knowing what’s covered for this diagnosis can give you confidence to focus on healing, not hospital bills.