What medical procedures are (and aren’t) covered by Medicare?

Medicare can be a complicated maze of coverage, co-pays and columns, but at Blue Cross and Blue Shield of Kansas, we want to simplify the details as much as possible to get direct information that impacts your future healthcare. Our team is also ready to get into the details of more than just procedure coverage and explain co-pays and deductibles as well. 

Medicare procedure plan coverage & definitions

The first step of determining coverage is if the treatment will be done as an inpatient or outpatient procedure. 

  • Medicare Part A: These plans cover inpatient hospital procedures
  • Medicare Part B: These plans cover outpatient procedures and related medical equipment
  • Medicare Advantage: These plans include both Part A & Part B

What is the difference between inpatient and outpatient? 

It’s important to know if you’re being treated as an inpatient or outpatient because that will impact the cost, coverage and additional medical items you might need once you return home. Your patient status hinges on if a Medicare-approved doctor writes an order that formally admits you to the hospital. 

  • Outpatient: These services are generally done through emergency rooms or ambulatory centers. A patient can even spend the night, but that would still be considered an outpatient stay if there isn’t a doctor’s order to admit you. 
  • Inpatient: With the doctor’s order, you will also need to be hospitalized for “two or more midnights” (two overnight stays in a row) to be considered a hospital inpatient.

HELPFUL TIP: Have your caregiver ask daily in a medical facility if you are being treated as an inpatient or outpatient. 

Medicare procedure coverage requirements

The next phrase to remember for any Medicare coverage is “Medically Necessary.” 

Medically Necessary: Healthcare services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. – Medicare.gov

Once a doctor determines the procedure is medically necessary, you can discuss if it will be done on an inpatient or outpatient basis. You’ll also need the hospital, emergency room, or ambulatory surgery center to accept the Medicare assignment.

What does Medicare cover?

Here’s an alphabetical list of procedures that are commonly covered under at least one Medicare plan. This is a broad stroke, but your Blue Cross and Blue Shield of Kansas representative can dig into more details with your plan, so you fully understand individual coverage.

  • Acupuncture
  • Ground or Air Ambulance Transportation
  • Auto Accident Injuries: Car insurance would pay first, then Medicare
  • Back surgery
  • Blood tests
  • Medically Necessary Non-cosmetic Breast Reduction Surgery
  • Nutrition therapy/Weight Loss Programs
  • Cataract surgery
  • Chemotherapy
  • Chiropractic services
  • Colonoscopy screenings
  • CT/PET/MRI Scans
  • Cancer treatment
  • Dermatology services
  • Dialysis
  • Echocardiograms
  • Endoscopy
  • ER Visits
  • Gender reassignment surgery: On a case-by-case basis
  • Genetic testing
  • Heart transplants
  • Hernia surgery
  • Hip/Knee replacement surgery
  • Hospital observation
  • Hysterectomy surgery
  • Laser spine surgery
  • Liver transplants
  • Macular degeneration treatment
  • Mental health services
  • Oral surgery
  • Outpatient surgery
  • Pap smears
  • PET Scans
  • Physical therapy
  • Podiatry
  • STD testing
  • Surgery
  • Thyroid tests
  • Eyelid surgery
  • Palliative care
  • Pregnancy
  • Allergy testing
  • Rehabilitation services: Review specific details of coverage
  • Stem cell therapy
  • Urgent care services
  • Varicose vein treatment
  • X-rays

Medicare inpatient coverage by location

Many approved treatments can be done in either a hospital, healthcare facility, or ambulatory surgery center. Medicare does cover care in the following locations: 

  • Acute care hospitals
  • Critical access hospitals
  • Inpatient rehabilitation facilities
  • Inpatient **psychiatric facilities
  • Long-term care hospitals

**Inpatient mental health care has a 190-day (approx. 6 months) lifetime limit

Even if a procedure is covered, there could be additional costs for devices or prescriptions needed for post-hospital care. You’ll need to review your Part D coverage options to see what is covered in the hospital vs. what is covered at home. 

FAQS: specific Medicare coverage topics

Here are the most common questions the Blue Cross and Blue Shield of Kansas team gets about specific procedures. Use these as a starting point for discussing with our knowledgeable and compassionate representatives. 

TAVR Procedure: Transcatheter Aortic Valve Replacement (TAVR) 

The groundbreaking TAVR treatment replaces a severely diseased or poorly functioning aortic valve. Six conditions must be met for TAVR to be considered for Medicare coverage. There are three conditions if the procedure is done as part of a clinical study.

Dental procedures

As a universal rule, dental procedures, exams and products aren’t covered by Medicare. A required hospital stay for an extreme procedure could be covered under Part A, but not the dental work itself. There are some Part C plans that might cover certain dental aspects and your representative will address your specific questions. 

Dermatology procedures 

With many skin issues that impact the health and appearance of Medicare recipients, it’s important to know where the line is drawn between medically necessary and cosmetic. For example, skin cancer removal would be covered, while a skin cancer screening with no precipitating risk factors for skin cancer would not. 

When dealing with skin tags, seborrheic keratosis, or moles, coverage is dependent on if the skin growths pose a risk or cause pain. Removing any of those for purely cosmetic reasons won’t be covered. Botox is also not covered for wrinkles but can be for migraine relief. 

Eye procedure 

Routine eye care and exams aren’t covered, but if you have associated risk factors – like diabetic retinopathy – you can get coverage. Glaucoma tests will be covered once a year for those with heightened risk factors. Age-related macular degeneration can also be covered. Any eye procedure or exam done in an outpatient setting will include a co-payment on top of the Part B costs. 

Does Medicare cover experimental procedures?  

When the right certifications and approvals are met, there is a good chance an experimental procedure would be covered by Medicare. However, you should not assume that it will be covered. Extensive conditions and requirements must be met. 

MORE: Search for Clinical Trials accepting Medicare Patients

How do I get coverage for dental, vision and hearing?

Blue Cross and Blue Shield of Kansas offers supplemental insurance for the common areas not covered by Original Medicare. That includes the following: 

What other procedure limitations should I know?   

Again we go back to “medically necessary” as the first threshold for coverage. For example, if you aren’t happy with the appearance of varicose veins but there is no medically-designated health risk, the procedures wouldn’t be covered.  Cosmetic surgery with no medical benefit, as determined by a doctor, will not be covered.

MORE DETAILS: A detailed booklet of items and services not covered by Medicare 

Medicare coverage outside the U.S. 

Here’s important information for any Medicare recipient planning a trip outside the country, whether driving, by air, or cruise ship. Medicare generally won’t cover procedures outside of the United States and its territories. This includes any medical facility owned and operated by a United States entity but still located outside of the country. 

Cruise ship passengers can only get coverage consideration if services were administered within six hours of departure or arrival at a U.S. port. Again, this holds true even if the ship is based out of the United States. 

TALK TO US, TRAVELERS: The Blue Cross and Blue Shield of Kansas team can help you with specific questions if you’re planning a cruise, overseas trip, or driving between the continental U.S. and Alaska through Canada.

How to find an estimated procedure price

Having coverage and being able to afford the coverage are very different things. You can use tools to determine the average procedure cost and compare prices by location, such as a hospital or surgery center. 

SEARCH: Outpatient procedure price search

Ask your doctor for the medical code to ensure you are searching for the correct procedure. For example, let’s say you have a torn meniscus. Using that search portal linked above, you might type in “Meniscus Repair,” which won’t yield results. The formal name for the procedure is “Arthroscopy, knee, surgical; with meniscus repair (medial or lateral),” and the code is 29882. Having the correct code makes searching easier and more accurate. 

Inpatient hospital costs will vary based on the following:

  • Length of time a patient is receiving treatment
  • If the deductible is met
  • If the patient is in a hospital, skilled nursing facility, or on hospice care

In three simple steps, you can also use the Blue Cross and Blue Shield of Kansas website to find care and cost estimates. You can also start shopping for our plans today by entering your zip code and county. 

Always ask about Medicare coverage, regardless 

Medicare recipients should know that there are exceptions to just about every procedure that isn’t commonly covered. The first step is knowing what your plan will cover. The Blue Cross and Blue Shield of Kansas team is dedicated to maximizing the value of our coverage and advocating for the best possible healthcare you can get. 

Our team is standing by to talk with you and answer all questions. Our patience with patients is unsurpassed. You can ask questions through our website, call us at 1-800-432-3990, or schedule a consultation online

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