Does Medicare Cover Aortic Aneurysm Surgery?

Medicare, a federal health insurance program, provides coverage for millions of Americans. It primarily serves individuals aged 65 or older, but also extends to younger people with specific disabilities and those diagnosed with End-Stage Renal Disease (ESRD). This article clarifies Medicare’s coverage for specialized medical procedures like aortic aneurysm surgery, including covered costs and financial responsibilities.

Medicare Parts and Services

Medicare has distinct parts: Original Medicare (Part A and Part B), Medicare Advantage (Part C), and Prescription Drug Plans (Part D).

Medicare Part A (Hospital Insurance) covers inpatient hospital care, skilled nursing facilities, hospice, and some home health services.

Medicare Part B (Medical Insurance) covers medically necessary services and preventive care, including doctor visits, outpatient care, durable medical equipment, and screenings. Part A covers hospital facility costs; Part B covers professional fees of doctors and other healthcare providers. Most people pay a monthly premium for Part B.

Medicare Advantage (Part C) offers an alternative to Original Medicare. These private plans cover all Part A and Part B benefits, often including Part D and additional benefits (e.g., vision, hearing, dental).

Medicare Part D helps beneficiaries with prescription drug costs. These private plans can be standalone or part of a Medicare Advantage plan.

Coverage for Aortic Aneurysm Care

Medicare covers aortic aneurysm care, from diagnosis to post-operative recovery.

Medicare Part B covers medically necessary diagnostic tests for diagnosis and screening (e.g., ultrasounds, CT scans, and MRIs). Medicare also offers a one-time abdominal aortic aneurysm (AAA) ultrasound screening for at-risk individuals who meet specific criteria.

Surgical procedures for an aortic aneurysm (open or endovascular repair, EVAR) are typically covered by Medicare Parts A and B. Part A covers the inpatient hospital stay, including the operating room, nursing care, and facility charges.

Medicare Part B covers professional services during surgery and hospital stay, including surgeon’s and anesthesiologist’s fees, and other medical professionals. Part B also covers necessary medical supplies and equipment. All covered services must be medically necessary, meeting accepted standards of medical practice.

Post-operative care and rehabilitation are also covered. Follow-up doctor visits fall under Part B. If rehabilitation services like physical or occupational therapy are required, Part B covers them when medically necessary. For short-term skilled nursing facility care after hospitalization, Part A may cover services for up to 100 days per benefit period, provided admission criteria are met. Prescription medications for recovery or ongoing management are covered under Medicare Part D.

Patient Costs

Beneficiaries are responsible for out-of-pocket costs, which vary by Medicare plan.

Under Original Medicare (Part A and Part B), patients face deductibles, co-insurance, and co-payments. For Part A, a deductible applies per benefit period before Medicare pays for inpatient hospital stays. After meeting this, Part A covers the first 60 days fully. Co-insurance applies for days 61-90, and separate daily co-insurance for “lifetime reserve days” beyond 90 days.

For Medicare Part B, an annual deductible must be met. After the deductible, Medicare typically covers 80% of the Medicare-approved amount for most doctor services, outpatient care, and durable medical equipment; beneficiaries are responsible for the remaining 20% co-insurance. For example, after aortic aneurysm surgery, the 20% co-insurance applies to surgeon’s fees, anesthesiologist’s services, and follow-up outpatient visits.

Medicare Advantage plans (Part C) have their own cost-sharing structures, including varying deductibles, co-payments, and co-insurance. These plans often feature an annual out-of-pocket maximum, limiting the total amount a beneficiary pays for covered medical services. Once this maximum is reached, the plan typically pays 100% of covered services. Costs and benefits differ among private insurer plans.

Many beneficiaries opt for Medigap policies (Medicare Supplement Insurance) to manage Original Medicare’s out-of-pocket costs. These private plans work with Original Medicare to cover some deductibles, co-payments, and co-insurance amounts Medicare does not pay. Medicare Part D plans have their own deductibles, co-payments, and co-insurance for prescription drugs.

Ensuring Coverage and Handling Denials

Understanding administrative requirements is key to navigating Medicare coverage for complex procedures like aortic aneurysm surgery, ensuring services are covered and providing a pathway for denied claims.

Some medical services, especially diagnostic tests or procedures for aortic aneurysm care, may require prior authorization from Medicare or the specific Medicare Advantage plan. Healthcare providers typically submit these requests to the insurer before the service to demonstrate medical necessity.

Medical necessity is central to Medicare coverage; Medicare only covers services and supplies considered reasonable and necessary for diagnosing or treating a medical condition. For aortic aneurysm care, diagnostic tests, surgical interventions, and post-operative therapies must be deemed appropriate by qualified medical professionals. If a service is not medically necessary, coverage may be denied.

Should a Medicare claim for aortic aneurysm care be denied, beneficiaries have the right to appeal. The appeals process involves several levels, each with specific deadlines and requirements:
Redetermination by the Medicare Administrative Contractor (MAC) that processed the original claim.
Reconsideration by a Qualified Independent Contractor (QIC) if the denial is upheld.
Review by an Administrative Law Judge (ALJ) at the Office of Medicare Hearings and Appeals (OMHA).
Review by the Medicare Appeals Council if the ALJ’s decision is unfavorable.
Judicial review in federal district court as the final administrative step.

Throughout this process, adhere to appeal deadlines and provide all supporting medical documentation and rationale.