Medicare covers most surgeries, but not all of them, and the amount you pay depends on which part of Medicare you have

If you have Original Medicare (Part A and Part B), surgery performed in a hospital or outpatient surgery center is covered. Part A covers the facility, the operating room, and your hospital stay if needed. Part B covers the surgeon's fee and the anesthesiologist. You will pay a deductible and coinsurance — the exact amounts depend on whether the surgery is inpatient or outpatient, and whether it happens in a hospital or a surgery center.

If you have a Medicare Advantage plan (Part C), your coverage works differently. These plans are run by private insurance companies and must cover everything Original Medicare covers, but they set their own rules about which surgeries need pre-approval, which hospitals you can use, and how much you pay out of pocket. Some surgeries may require you to get permission from your plan before you schedule them.

Not every surgery is covered. Medicare does not pay for cosmetic surgery, experimental procedures, or surgeries that are deemed not medically necessary. Your doctor and Medicare will determine whether your surgery meets the medical necessity standard.

Key Takeaways

  • Original Medicare Part A covers the hospital facility and operating room; Part B covers the surgeon and anesthesiologist, but you pay a deductible and coinsurance.
  • Medicare Advantage plans cover the same surgeries as Original Medicare but may require pre-approval and limit which hospitals you can use.
  • You should contact your plan or call Medicare before scheduling surgery to learn your exact out-of-pocket costs and whether pre-approval is needed.
  • Cosmetic surgery, experimental procedures, and surgeries deemed not medically necessary are not covered by any Medicare plan.
  • If your surgery is denied, you have the right to appeal the decision, and your doctor can help you submit medical records to support your case.

How Original Medicare pays for inpatient surgery

Inpatient surgery means you stay overnight in the hospital. Part A covers the hospital stay, operating room, meals, nursing care, and most supplies. You pay the Part A deductible (the amount changes each year) for the first day of your stay. After that, you pay nothing for days 1 through 60. From day 61 to day 90, you pay a daily coinsurance amount. If you stay longer than 90 days, the costs rise further.

Part B covers the surgeon's fee, the anesthesiologist's fee, and the pathologist's fee if tissue is examined during surgery. You pay 20 percent of the Medicare-approved amount for these services after you meet your Part B deductible for the year. The surgeon's office will bill Medicare directly, and Medicare will send you an explanation of benefits showing what they paid and what you owe.

Before surgery, ask your surgeon's office to tell you the Medicare-approved amount for your procedure. This is not the same as the surgeon's regular fee — it is the amount Medicare has decided is reasonable for that surgery in your area. You are responsible for 20 percent of that approved amount, not 20 percent of whatever the surgeon normally charges.

How Original Medicare pays for outpatient surgery

Outpatient surgery means you go home the same day. Part A covers the facility fee for the surgery center or hospital outpatient department. Part B covers the surgeon, anesthesiologist, and other doctors involved. You pay the Part A deductible once per year, and then you pay 20 percent coinsurance for the facility. You also pay 20 percent coinsurance for the surgeon and other doctors after you meet your Part B deductible.

The total out-of-pocket cost for outpatient surgery is often lower than for inpatient surgery because you are not paying daily hospital coinsurance. However, the exact amount depends on the type of surgery, where it is performed, and whether you have already met your deductibles for the year.

Some outpatient surgeries are performed in a doctor's office rather than a surgery center. If your surgeon performs the procedure in their office, Part B covers it, and you pay 20 percent coinsurance after your deductible. The office does not charge a facility fee in this case.

Medicare Advantage coverage for surgery

Medicare Advantage plans must cover all surgeries that Original Medicare covers, but they often have additional rules. Many plans require prior authorization — you or your doctor must contact the plan and get written approval before the surgery is scheduled. If you have surgery without getting prior authorization, the plan may deny the claim or charge you a higher out-of-pocket cost.

Medicare Advantage plans also maintain networks of hospitals and surgeons. If you have surgery at an out-of-network facility, you may pay more or the plan may not cover it at all. Before scheduling surgery, check your plan's website or call the member services number on your insurance card to confirm that your surgeon and the facility are in network.

Your out-of-pocket costs with a Medicare Advantage plan depend on your specific plan. Some plans have a copay for surgery (a flat fee like $250), while others use coinsurance (a percentage like 20 percent). Some plans have an annual out-of-pocket maximum — once you reach that amount, the plan pays 100 percent of covered services for the rest of the year.

What to do before you schedule surgery

Contact your Medicare plan or Original Medicare before you schedule any surgery. If you have Original Medicare, call 1-800-MEDICARE and tell them about the surgery you are planning. They can tell you whether the procedure is covered and what your out-of-pocket costs will be. Ask them to send you a written estimate.

If you have a Medicare Advantage plan, call the member services number on your insurance card. Ask whether the surgery needs prior authorization, whether your surgeon and facility are in network, and what your copay or coinsurance will be. Get the answers in writing if possible.

Give your surgeon's office the same information. Tell them you have Medicare and ask them to verify your coverage before the surgery date. Many offices have staff who specialize in insurance verification and can tell you exactly what Medicare will pay and what you will owe.

Surgeries that Medicare does not cover

Medicare does not cover cosmetic surgery — surgery performed to improve appearance rather than to treat a medical condition. For example, Medicare will not pay for a facelift, liposuction, or breast augmentation. However, if cosmetic surgery is medically necessary (for example, reconstructive surgery after an accident or cancer treatment), Medicare may cover it.

Medicare does not cover experimental procedures — surgeries that are still being tested and have not yet been approved by the Food and Drug Administration (FDA) for routine use. If your doctor recommends an experimental surgery, ask whether it is part of a clinical trial. Some clinical trials cover the cost of the experimental procedure.

Medicare does not cover surgeries deemed not medically necessary. This means Medicare has determined that the surgery is not the standard treatment for your condition, or that the evidence does not support it as an effective treatment. If Medicare denies your surgery, your doctor can appeal the decision by submitting medical records and a letter explaining why the surgery is necessary for your specific case.

What happens if Medicare denies your surgery

If Medicare or your Medicare Advantage plan denies coverage for your surgery, you receive a written notice explaining the reason. The notice will tell you that you have the right to appeal. You have 120 days from the date of the denial to file an appeal.

To appeal, ask your doctor to submit additional medical records, test results, or a letter explaining why the surgery is medically necessary for you. Your doctor's support is crucial — Medicare is more likely to reverse a denial if your doctor provides strong clinical evidence. Your surgeon's office can help you gather the documents and submit the appeal.

If the appeal is denied, you can request a hearing before a Medicare administrative law judge. This process takes longer but gives you a chance to present your case in more detail. Your doctor or a patient advocate can attend the hearing with you.

Frequently Asked Questions

Do I need to pay anything upfront before surgery if I have Medicare?

You may need to pay your deductible before surgery if you have not met it yet for the year. Original Medicare Part A has an annual deductible, and Part B has a separate annual deductible. Ask your surgeon's office to estimate your out-of-pocket costs before the surgery date so you know what to expect.

What if my surgery costs more than Medicare allows?

If you have Original Medicare and your surgeon is a Medicare-participating provider, they have agreed to accept Medicare's approved amount as payment in full. They cannot bill you for the difference. If your surgeon is a non-participating provider, they can charge you up to 15 percent more than Medicare's approved amount, and you are responsible for that extra cost.

Does Medicare cover surgery at an urgent care center or emergency room?

Yes, if the surgery is medically necessary. Emergency surgery is covered under Part A. Urgent care centers are not hospitals, so coverage depends on whether the center is certified to perform surgery and whether the procedure is covered. Call Medicare or your plan before going to an urgent care center if possible.

Can I use my Medigap or Medicaid to help pay for surgery costs?

Yes. If you have a Medigap policy, it may cover some or all of your deductibles and coinsurance. If you also have Medicaid, it may help pay your Medicare costs. Contact your Medigap insurer or your state Medicaid office to learn what they will cover for your specific surgery.

What if I travel out of state for surgery?

Original Medicare covers surgery anywhere in the United States, as long as the facility is Medicare-certified. Medicare Advantage plans may have different rules — some cover out-of-state surgery, and some do not. Call your plan before traveling to confirm coverage.