Cerumen, commonly known as ear wax, serves a natural protective function in the ear canal, but excessive buildup can lead to a condition called cerumen impaction. When this blockage occurs, it can cause symptoms such as hearing loss, pain, or dizziness, often requiring professional removal.
For individuals with Medicare, coverage for this service is not automatic and depends heavily on the specific medical context of the removal. Whether the procedure is covered is determined by a strict set of rules that distinguish between a routine cleaning and a medically required intervention.
Original Medicare Coverage: The Rule of Medical Necessity
Original Medicare, which includes Part B for outpatient medical services, covers cerumen removal only when it is deemed medically necessary. This means the service is covered if the ear wax is impacted, defined as a hardened mass blocking the ear canal and causing specific symptoms or preventing a necessary medical examination.
The impaction must be causing issues like hearing loss, pain, tinnitus (ringing in the ears), or chronic ear infections. A healthcare provider must document that the cerumen is impacted and that its removal is required to treat a symptom or complication.
The removal must typically be performed by a physician or other qualified professional using specialized instruments, such as a curette, forceps, or suction device, which is often billed using a specific Current Procedural Terminology (CPT) code, like 69210.
Medicare does not cover the removal if the cerumen is not impacted or if the procedure is considered routine hygiene or preventative care. Simple, non-impacted removal is generally considered part of an office visit and is not separately payable.
Understanding Your Out-of-Pocket Costs
If the cerumen removal meets the strict medical necessity criteria under Original Medicare Part B, the beneficiary will be responsible for certain out-of-pocket costs. Medicare Part B pays 80% of the Medicare-approved amount for the service, meaning the patient is responsible for the remaining 20% coinsurance.
This 20% coinsurance applies after the annual Part B deductible has been met for the year. The Medicare-approved amount for a medically necessary removal may range between approximately $28 and $63, which means the patient’s 20% coinsurance could be roughly $6 to $12, assuming the deductible has been satisfied.
If the provider does not accept Medicare assignment—meaning they have not agreed to accept the Medicare-approved amount as full payment—they may charge the patient a small additional amount, known as an excess charge.
Coverage Through Medicare Advantage Plans
Medicare Advantage (MA) plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans must cover everything that Original Medicare covers, so medically necessary cerumen removal that meets the impaction criteria is included.
However, the patient’s out-of-pocket costs, such as copayments and deductibles, will differ from those under Original Medicare. Instead of the standard 20% coinsurance, MA plans typically require a fixed copayment for office visits and procedures, which can vary significantly depending on the specific plan.
Beneficiaries may also need to use providers within the plan’s network and may need a referral for specialist services. Some Medicare Advantage plans offer supplemental benefits that Original Medicare does not, which can include coverage for routine ear care, such as non-impacted or preventative ear cleaning.
Beneficiaries must consult their plan’s specific Evidence of Coverage document to understand the exact cost and coverage.