What Medicare covers for Axonics therapy

Medicare Part B covers Axonics therapy — a neurostimulation treatment for overactive bladder and bowel control problems — but only under specific conditions. The device itself and the surgical implant procedure are covered when your doctor documents that you have tried other treatments first and they did not work. You will pay 20 percent of the Medicare-approved amount after you meet your Part B deductible, and the remaining 80 percent is covered by Medicare.

The key requirement is that Axonics is considered a treatment of last resort. Medicare will not pay for the device if you have not already tried and failed conservative treatments like medications, pelvic floor physical therapy, or behavioral changes. Your urologist or urogynecologist must submit documentation showing what you tried, when you tried it, and why it did not work for you.

Key Takeaways

  • Medicare Part B covers the Axonics device and implant surgery when prior treatments have failed, with you paying 20 percent coinsurance after your deductible.
  • Your doctor must document that you tried medications, pelvic floor therapy, or other conservative treatments before Medicare will consider the device medically necessary.
  • The approval process typically takes several weeks because Medicare requires detailed medical records showing your treatment history.
  • If you have a Medigap or Medicare Advantage plan, your out-of-pocket costs may be lower, but coverage rules vary by plan.

How the approval process works

Before your doctor can schedule the implant surgery, they must submit a request to Medicare for prior authorization. This is not something you do yourself — your urologist's office handles the paperwork. They will send your medical records, test results showing your condition, and a letter explaining why Axonics is medically necessary for you specifically.

Medicare reviews this request and typically responds within 10 to 14 business days. If approved, you receive a letter saying the device and procedure are covered. If denied, you have the right to appeal, and your doctor can provide additional information to support the case. Many denials are overturned on appeal when the doctor provides clearer documentation of failed prior treatments.

The entire timeline from initial request to surgery approval usually takes three to six weeks. During this time, your symptoms do not stop, so talk with your doctor about managing your condition while you wait.

What you pay out of pocket

Your costs depend on whether you have Original Medicare alone or a supplemental plan. With Original Medicare Part B, you pay 20 percent coinsurance of the Medicare-approved amount for both the device and the surgical procedure. The exact dollar amount varies by region and by the specific facility where your surgery is performed, but the device itself typically costs Medicare several thousand dollars, meaning your 20 percent share could range from several hundred to over a thousand dollars.

If you have a Medigap policy (supplemental insurance), it may cover some or all of your coinsurance, depending on which Medigap plan you own. Plans C, D, G, and M cover Part B coinsurance, while other plans do not. If you have a Medicare Advantage plan instead of Original Medicare, your costs work differently — you may have a copay for the procedure instead of coinsurance, but you should check your plan's summary of benefits to know your exact responsibility.

You will also pay your Part B deductible (currently $240 per year, though this amount changes annually) before coinsurance kicks in, unless you have already met it earlier in the year.

What conditions may have access to for Axonics coverage

Medicare covers Axonics for two main conditions: overactive bladder and fecal incontinence. For overactive bladder, you must have symptoms like urgent need to urinate, frequent urination (eight or more times per day), or nighttime urination that significantly affects your daily life. For fecal incontinence, you must have involuntary loss of stool that happens regularly and has not improved with other treatments.

In both cases, Medicare requires that you have tried and failed at least one conservative treatment first. For overactive bladder, this usually means trying anticholinergic medications like oxybutynin or tolterodine, or behavioral strategies like scheduled voiding and fluid management. For fecal incontinence, it may mean trying dietary changes, bowel training, or medications that firm stool.

Your doctor will need to document your symptoms in detail and explain why your specific situation makes you a good candidate for the device. Medicare does not cover Axonics for mild symptoms or for people who have not genuinely tried other options.

Medicare Advantage plans and Axonics coverage

If you have a Medicare Advantage plan (Part C), coverage for Axonics varies by plan and by insurance company. Some plans cover it with the same requirements as Original Medicare — prior treatment failure and prior authorization. Other plans may not cover it at all, or may cover it only under different conditions.

You need to check your specific plan's coverage document, called the Summary of Benefits and Coverage, or call your plan's member services line to ask whether Axonics is covered. Do not assume that because Original Medicare covers it, your Advantage plan does. The answer depends entirely on which plan you chose and which insurance company runs it.

If your Advantage plan does not cover Axonics, you have the option to switch to Original Medicare during the annual open enrollment period (October 15 to December 7 each year), though you would need to enroll in a Medigap plan at the same time to cover costs.

What happens if Medicare denies coverage

If Medicare denies your prior authorization request, you can appeal the decision. Your doctor's office can submit additional medical records, test results, or a detailed letter explaining why Axonics is medically necessary for you. Many initial denials are reversed on appeal when the documentation is clearer or more complete.

You have 120 days from the date of the denial letter to file an appeal. Your doctor can help you with this process, and some urology practices have staff who specialize in insurance appeals. If the appeal is also denied, you can request an independent review by a Medicare contractor who was not involved in the original decision.

If you believe Medicare's decision is wrong, you can also file a complaint with your state's insurance commissioner or contact your local Area Agency on Aging for help navigating the appeals process.

Frequently Asked Questions

Do I have to try medications before I can get Axonics?

Yes. Medicare requires that you have tried at least one conservative treatment — usually medication, pelvic floor physical therapy, or behavioral strategies — and that it did not work for you. Your doctor must document this in your medical record before submitting the prior authorization request. If you have never tried medication, Medicare will likely deny coverage until you do.

How long does the prior authorization process take?

Medicare typically responds to a prior authorization request within 10 to 14 business days. However, the entire timeline from when your doctor first decides you are a candidate to when you have surgery can be three to six weeks, depending on how quickly your doctor's office gathers records and submits the request, and how quickly Medicare reviews it.

Will my Medigap plan pay for the part Medicare does not cover?

It depends on which Medigap plan you have. Plans C, D, G, and M cover Part B coinsurance, so they would pay your 20 percent share. Plans A, B, F, K, L, and N do not cover Part B coinsurance. Check your Medigap policy documents or call your insurance company to confirm what your specific plan covers.

What if I have a Medicare Advantage plan and it does not cover Axonics?

You can appeal the denial through your Advantage plan's appeals process, or you can switch to Original Medicare during open enrollment (October 15 to December 7). If you switch, you will also need to enroll in a Medigap plan to help cover costs. Keep in mind that switching plans means changing your doctors and network, so weigh that decision carefully with your urologist.

Can I get Axonics if I have not tried every possible treatment?

Medicare's requirement is that you have tried at least one conservative treatment and it did not work. You do not have to try every possible medication or therapy, but you do have to try something and have documentation that it failed. Your doctor can argue that a particular treatment is not appropriate for your situation, which may satisfy Medicare's requirement without you actually taking that treatment.