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Medicare Surgery Coverage: Essential vs. Non-Essential Surgery Under Medicare

Posted on March 8, 2022 by Larry Johnson

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"I'm Looking to Have Surgery - Will Medicare Cover It?"

If you’re relatively new to having Medicare coverage, learning what types of services it will or will not cover can seem overwhelming. This is especially true for surgical procedures.

One of the questions we hear often is “Does Medicare cover surgery?” The short answer is “yes.” The longer answer, which we’ll elaborate upon as you read this blog, is still “yes,” but there are certain conditions that your procedure must meet before Medicare surgery coverage will cover some or all of the costs incurred.

Let’s take a look at what Medicare may or may not cover in regards to surgical procedures.

Essential vs. Non-Essential

Medicare.gov notes that they cover “many medically necessary surgical procedures.” However, what exactly dictates whether or not a surgical procedure is medically necessary? A big part of what makes a surgical procedure medically necessary is whether or not it’s needed to help treat a serious existing condition.

Medicare breaks down surgical procedures into two categories: essential surgery, or medically necessary surgery, and non-essential surgery. Let’s break down what makes a surgical procedure essential or non-essential.

Essential Surgery

As we mentioned above, an essential surgery is the same thing as a medically necessary surgery. This means that the surgical procedure in question is crucial to helping you treat a debilitating or life-threatening condition and helping you maintain a comfortable standard of living. These are the types of surgical procedures that are covered under Medicare surgery coverage.

Take, for example, bariatric surgery. Original Medicare will cover certain forms of bariatric surgery, such as gastric bypass and laparoscopic banding, as long as you meet certain conditions related to morbid obesity. Some of the conditions that you’d have to meet for bariatric surgery to be deemed an essential surgery to be covered by Medicare include:

  • A body mass index (BMI) of 35 or higher.
  • Documented evidence that you’ve been obese for the last five years.
  • You suffer from obesity-related co-morbidities, such as sleep apnea or diabetes.
  • Documented participation in a medically-supervised weight loss program*.

*Your documentation will often need to show that you have participated in and failed more than one medically-supervised weight loss program.

Non-Essential Surgery

Surgery to correct an issue that isn’t life-threatening, such as surgery performed for cosmetic reasons, is considered non-essential surgery. As non-essential surgery is not considered “medically essential,” it is not covered by Medicare.

One of the most obvious examples of a non-essential surgery would be a procedure like liposuction. It can help you sculpt your body and boost your self esteem, but it isn’t a procedure that you need to treat a life-threatening illness or condition. It is not medically essential because it does not effectively treat morbid obesity, only a symptom of the disorder. In fact, plastic surgery of any sort is considered non-essential, and therefore not covered by Medicare.

If you’re looking to have a tooth filled or you’re wanting to schedule LASIK, it’s important to know that these types of procedures are also considered non-essential surgery under the Medicare banner and are therefore not covered. However, certain forms of oral surgery or corrective vision procedures may be covered under Medicare surgery coverage as they could be considered medically essential.

When you’re seeking out a surgical procedure that Medicare will not cover, certain insurance agencies offer a form of surgery insurance. If you choose to purchase separate surgery insurance, do make sure that certain procedures you are looking to have would be covered. Be sure to do plenty of research on the surgery insurance of your choice before you opt to buy.

*You should also make sure that your provider will give you the go-ahead for a non-essential surgery at this time. Many healthcare providers are refusing to perform non-essential procedures per CMS recommendation due to resources and bed space being needed to treat COVID-19.

Exceptions to the Rule

There are times when a procedure typically considered to be a non-essential surgery would fall under the essential surgery category. If something that would typically be corrected with a non-essential surgery has become a life-threatening condition, Medicare will then cover costs for that procedure.

Oral surgeries are typically seen as non-essential surgeries. However, there are times when an oral surgery would be considered medically essential and could be covered by Medicare surgery coverage. If you require reconstructive dental or oral surgery due to the occurrence of some form of traumatic injury, that surgery would become essential and would be covered by Original Medicare

Another type of surgery that would be viewed as non-essential would be corrective vision surgery. Conditions that drastically affect your vision pose a serious risk of harm, and therefore could be life-threatening. A common condition among seniors that can drastically alter vision is the development of cataracts. As a result, cataract surgery is covered by Medicare surgery coverage.

In any instance, if you’re wondering whether your surgical procedure may be covered by Medicare, your best move is always to check their policy. You may need a procedure that seems like a non-essential surgery on the surface, but could be deemed medically necessary if it poses any threat to your health. You can also call a Medicare representative at 1-800-MEDICARE if you need to know whether or not a surgery that would possibly be viewed as non-essential surgery may be covered.

Be Proactive - Make Sure Your Procedure is Covered

When you need a crucial procedure to combat the effects of a life-threatening illness, Medicare surgery coverage can be a massive help. The cost of most essential surgical procedures is incredibly high. Medicare surgery coverage can help lighten the financial burden of getting an essential surgery that you need to improve your quality of life.

However, if the surgery that you’re looking for isn’t covered, you may be in for serious sticker shock once the bill comes around. If you scheduled a procedure that you thought was covered by Medicare surgery coverage and it actually isn’t, you might just end up on the hook for tens of thousands of dollars in order to cover the cost of a procedure that’s considered a non-essential surgery.

Before you have any procedure performed, check your Medicare policy to make sure that the service you need is covered. Remember that Original Medicare will not cover most cosmetic, oral, or visual procedures. It’s also helpful to know that if your procedure is not covered by Original Medicare, separate surgery insurance or a Medicare Advantage plan can help you mitigate the cost.

About the Author

Larry Johnson

Larry is a content writer with several years of experience in creating informative content for a variety of industries on topics that matter. He is a 2009 graduate of the University of North Carolina School of the Arts.

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