Does Medicare Cover Surgery?
Key Takeaways
- Original Medicare (Parts A and B) covers medically necessary surgery, as well as hospital stays, approved supplies and equipment, and related diagnostic and recovery services.
- You must pay your Part A or Part B deductible before coverage kicks in, and you may still owe coinsurance or other out-of-pocket costs.
- Some procedures and Medicare Advantage plans may include specific requirements, such as pre-authorization for surgery coverage.
- Medicare does not cover elective or cosmetic surgical procedures.
Medicare does cover many surgeries, provided the procedure is deemed medically necessary by a physician or specialist. Original Medicare (Part A and Part B) covers medically necessary inpatient and outpatient surgeries. Elective surgeries, including experimental or cosmetic procedures, generally are not covered by Medicare.
The facility and physician must accept Medicare for a patient to get coverage. If you’re on a Medicare Advantage plan from a private insurance carrier, you may need to receive care from a healthcare provider in your plan’s network. Additionally, some surgeries require pre-authorization. Read on to explore the factors affecting Medicare coverage for surgery.
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Inpatient vs. Outpatient Surgeries
Medicare Part A, Medicare Part A (hospital and inpatient insurance) covers surgeries like heart transplants and joint replacements, while Medicare Part B, (medical and outpatient insurance) covers procedures that can be done in an outpatient setting, such as cataract correction. Surgery coverage is critical for Medicare-eligible seniors in the United States.
In a recent study published by the National Library of Medicine, for every 100 people age 65 or older in the U.S., an average of nine surgeries were performed each year. This equates to more than one in seven Medicare beneficiaries, or roughly 5 million seniors, undergoing at least one major surgery during the last five years.
What Surgeries Does Medicare Cover?
Medicare covers medically necessary surgeries but does not extend coverage to elective procedures. Additional conditions may apply. For example, Medicare only covers hip replacement surgery following unsuccessful attempts at other non-surgical treatment options. The following are examples of some of the most common Medicare-eligible surgeries affecting seniors today:
- Cataract surgery
- Bariatric surgery
- Organ transplant surgery
- Hip replacement surgery
- Breast prosthesis (outpatient) surgery, following a mastectomy
- Surgeries to treat injuries, such as repairs to broken bones
- Surgeries to treat medical conditions, such as removing tumors and cardiac rehabilitation surgeries
Does Medicare Cover Cataract Surgery?
Once you meet your Part B deductible, Medicare covers 80% of the cost of medically necessary cataract surgery involving standard intraocular lenses. Medicare also covers one pair of eyeglasses with standard frames or contact lenses following cataract surgery.
Does Medicare Cover Oral Surgery?
Medicare typically does not cover routine dental procedures or oral surgery. However, Medicare may cover a procedure, such as a tooth extraction to treat a mouth infection, if it is medically necessary before receiving Medicare-approved chemotherapy or dialysis. Medicare also covers some dental services like oral exams prior to an organ transplant, and treatment for dental complications that may arise when you are receiving Medicare services.
Does Medicare Cover Bariatric Surgery?
Medicare may cover bariatric surgery for beneficiaries who have a body mass index (BMI) of 35 or higher, at least one comorbidity, and have made unsuccessful attempts at other non-surgical weight loss treatments. Standard bariatric procedures include gastric bypass surgery and laparoscopic banding surgery.
You may have a choice between inpatient or outpatient surgery, depending on your condition, which will determine whether Part A or Part B covers the majority of the cost.
What Surgeries Does Medicare Not Cover?
Medicare does not cover elective surgeries or procedures not deemed medically necessary by a treating physician. The following are examples of surgeries not covered by Medicare:
- LASIK surgery: Medicare does not cover LASIK because it is an elective corrective procedure. However, Medicare does cover one pair of eyeglasses or contacts after cataract surgery.
- Cosmetic surgeries: Medicare does not cover cosmetic procedures that are not medically necessary, even if it can decrease discomfort. For example, dental implants to replace missing teeth can improve a beneficiary’s comfort, but it is not considered medically necessary.
- Sterilization surgery: Medicare does not cover elective sterilization procedures, such as vasectomies or tubal ligation for sterilization.
- Experimental or investigative surgery: The procedure must be widely accepted and known to be effective through medical research and clinical trials to get coverage.
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How Medicare Advantage Covers Surgery
Medicare Advantage, also known as Medicare Part C, replaces federal Original Medicare coverage. These plans are offered by private insurers and bundle Part A and Part B benefits together.
All Medicare Advantage plans must provide the same level of coverage as Original Medicare at minimum. However, many offer extended benefits. For example, Medicare Advantage Prescription Drug Plans include Part D drug coverage, which is not part of Original Medicare. Medicare Advantage benefits differ by plan, carrier, and service area.
Do You Need Preauthorization for Surgeries With Medicare?
Generally, Medicare Part A does not require preauthorization for surgery. However, preauthorization may be required for certain Part B outpatient procedures.
Medicare Advantage plans sometimes require preauthorization, especially for complex or expensive surgical procedures, though specific terms vary by plan.
How Much Does Surgery Cost With Medicare?
Though Medicare generally covers medically necessary surgery and hospitalization costs, you may still be responsible for some out-of-pocket expenses. At a minimum, you pay monthly premiums for Part B ($185 in 2025) and must meet a deductible before your coverage kicks in: $257 per year for Part B and $1,676 per benefit period for Part A in 2025 .
Medicare Part A covers inpatient surgery once you meet your deductible. You may owe coinsurance beyond the Part A deductible for extended hospital stays or nursing facility benefits.
Medicare Part B typically covers 80% of the cost of outpatient medical costs after you meet your deductible, which means you owe the remaining 20%.
Take hip replacement surgery, one of the most common surgeries among seniors, according to AARP. Hip replacement surgery would cost an uninsured individual approximately $11,000-$14,000. However, Medicare beneficiaries could pay an average of just $2,100, depending on whether they undergo the procedure at a hospital or surgical center.
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Other Medicare Benefits to Consider
You may need to utilize additional benefits related to surgery. The following are examples of other Medicare-covered benefits related to the surgery itself and the recovery process:
- Skilled nursing facilities: While Medicare Part A covers inpatient surgery in a hospital or surgical center, you may still require a period of care in a skilled nursing facility to recover after major surgery. Part A will also cover up to 100 days of care in a skilled nursing facility after a qualifying hospital stay.
- Occupational therapy: You may need help relearning how to perform daily functions after a major surgical procedure and hospitalization. Medicare Part B covers the evaluation, treatment and activities, and approved DME for medically necessary occupational therapy following surgery.
- Home healthcare: Medicare covers select home healthcare services for beneficiaries who are recovering from a surgical procedure. Benefits may include intermittent (not 24/7) skilled nursing care, speech-language pathology, and medical social services.
- Medical supplies and DME: You may need supplies and DME to support your recovery after a major surgery. Medicare may cover 80% of the cost of supplies and equipment, such as oxygen machines, walkers, and wheelchairs.
Putting It All Together
Does Medicare cover surgery? Yes, provided the surgery is medically necessary to treat an injury, disease, or medical condition. Part A covers inpatient surgeries and hospital stays and Part B covers outpatient surgeries, as well as some after-care and DME. However, you may still be responsible for some out-of-pocket expenses, such as coinsurance and annual deductibles before cost sharing. Medicare does not cover elective surgeries.
Sources
- Surgery. Medicare.gov
- Surgery. CMS.gov
- 5 Things to Know About Hip Replacement Surgery. AARP.org
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