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Does Medicare pay for all surgeries?

Medicare only covers medically necessary surgical procedures. Medicare defines medically necessary services as “health care services or supplies that are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms – and that meet accepted standards of medicine.” Medicare further defines medically necessary services as ones that:

  • Are proper and needed for the diagnosis or treatment of your medical condition.
  • Are provided for the diagnosis, direct care, and treatment of your medical condition.
  • Meet the standards of good medical practice in the local area and are not mainly for your or your doctor’s convenience.

To see a list of covered services, including surgeries, you can search the Medicare website. If you are enrolled in a Medicare Advantage plan, they may cover additional surgeries not covered under original Medicare. For both original Medicare and Medicare Advantage, if you are unsure if a surgery you are considering or need is covered, talk to your doctor, Medicare, or your Medicare Insurance company. In most cases, experimental surgeries are not covered by Original Medicare or Medicare Advantage plans. If you are considering having an experimental surgery, check with your doctor to see if it will be covered before you get the surgery.

Even if a surgery is covered, you may still have out-of-pocket costs in the form of deductibles, coinsurance, or copays that you are required to pay.

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