Question 1

Does Medicare cover shoulder replacement surgery?

Accepted Answer

Yes. Medicare covers total shoulder replacement and reverse total shoulder arthroplasty (CPT 23472) when medically necessary. Reverse shoulder replacement — the most common type in Medicare patients — is fully covered. Medicare pays 80% of the approved surgeon fee and facility fee under Part B (outpatient) or Part A (inpatient). Prior authorization is not required for shoulder replacement under traditional Medicare, though Medicare Advantage plans may require it.

Question 2

Is reverse shoulder replacement covered by Medicare?

Accepted Answer

Yes. Reverse total shoulder arthroplasty (CPT 23473) is covered by Medicare when medically necessary, typically for rotator cuff tear arthropathy or failed previous shoulder surgery. It is the most commonly performed shoulder replacement in Medicare patients and has been covered since CMS approved it for widespread use. Coverage applies to both the surgeon fee (Part B) and facility fee (Part B outpatient or Part A inpatient).

Question 3

What is the Medicare cost for shoulder replacement in an ASC vs hospital?

Accepted Answer

The ASC facility fee for shoulder replacement is approximately $9,393, compared to $13,116 at a hospital outpatient department (HOPD) — a savings of $3,723 in facility fees. Your 20% share would be $1,879 at an ASC vs $2,623 at an HOPD. Not all surgeons perform shoulder replacement in an ASC; ask your surgeon if they have ASC privileges and if you are a suitable outpatient candidate.

Question 4

Why does this calculator show a different amount than Medicare.gov's cost estimate?

Accepted Answer

This calculator may show a higher number than Medicare.gov's "Patient Pays (average)" for several reasons: (1) Deductible timing — this calculator applies the $283 Part B annual deductible if it has not yet been met; Medicare.gov's average assumes many patients have already satisfied theirs. (2) Anesthesia — Medicare.gov's estimate covers the facility fee and surgeon only; anesthesia is billed separately and is included in this calculator. (3) Location adjustment — surgeon fees are adjusted by your region's Geographic Practice Cost Index (GPCI); in high-cost cities like Seattle or New York, surgeon fees run 30–50% above the national rate. Facility fees (HOPD and ASC) are nationally fixed by CMS and should match Medicare.gov exactly. (4) Patient mix — Medicare.gov's "Patient Pays" average includes Medigap enrollees who pay $0 coinsurance, which pulls the reported average below what uninsured Original Medicare patients typically pay.

Cost Component	Medicare-Approved Amount	Your Share (20%)
Surgeon Fee — Shoulder Replacement (CPT 23472)	$1,300	$260
Hospital Outpatient (HOPD) Facility Fee	$17,913	$3,583
Ambulatory Surgery Center (ASC) Facility Fee	$13,911	$2,782
Inpatient Hospital (DRG 483) — Medicare Pays	$20,170	$1,736 Part A deductible
Anesthesia (estimated)	$800–$1,400	20% of approved

Medicare Shoulder Replacement Cost 2026 | Out-of-Pocket Estimator

2026 Medicare Cost Summary — Shoulder Replacement (CPT 23472)

What Medicare Pays

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