Does Medicare Cover Kidney Stone Removal?

Medicare generally covers medically necessary diagnosis and treatment of kidney stones. This includes various procedures and associated services. Understanding how Medicare covers these treatments involves examining its different components and potential financial responsibilities.

Original Medicare Coverage for Kidney Stone Removal

Original Medicare, consisting of Part A (Hospital Insurance) and Part B (Medical Insurance), covers medically necessary kidney stone removal services. The specific Medicare part covering treatment depends on where services are provided and the nature of care. All covered services must meet the definition of medical necessity.

Medicare Part A covers inpatient hospital stays, including surgical procedures for kidney stone removal performed during an admission. If a physician admits a beneficiary to the hospital, Part A covers the inpatient stay. This includes costs for a hospital room, nursing care, and hospital supplies related to the inpatient procedure. Common surgical procedures like percutaneous nephrolithotomy, which removes large stones through a small back incision, are covered under Part A in an inpatient setting.

Part A also covers other inpatient procedures like ureteroscopy with stent placement or lithotripsy, if they require an inpatient hospital admission. These services are covered as part of the overall hospital stay. Part A coverage is for services received as an admitted inpatient, not for outpatient observation stays. The distinction between inpatient and observation status impacts coverage and costs.

Medicare Part B covers a range of outpatient services, including doctor’s visits and diagnostic tests. This includes consultations with specialists like urologists, and imaging tests such as X-rays, CT scans, and ultrasounds, used to diagnose kidney stones and plan treatment. Laboratory tests, including blood and urine analyses, are also covered under Part B for diagnostic purposes.

Outpatient surgical procedures for kidney stone removal are covered under Part B if performed in an outpatient setting or an ambulatory surgical center. Non-invasive treatments like extracorporeal shock wave lithotripsy (ESWL), which uses sound waves to break up stones, are covered as outpatient services. Follow-up care, including post-procedure evaluations and medical management, also falls under Part B coverage. Medicare Part B covers 80% of the Medicare-approved amount for these services after the annual deductible is met.

Patient Financial Responsibility Under Original Medicare

Beneficiaries with Original Medicare generally incur out-of-pocket costs for kidney stone removal. These costs include deductibles, coinsurance, and copayments, depending on the services received. These financial obligations apply before Medicare pays its share for covered services.

For inpatient hospital stays covered by Medicare Part A, a deductible applies per benefit period. In 2025, this inpatient hospital deductible is $1,676. A benefit period begins when a beneficiary is admitted as an inpatient and ends after 60 consecutive days without inpatient care.

If a hospital stay extends beyond 60 days within a benefit period, daily coinsurance amounts apply. For days 61 through 90, the daily coinsurance in 2025 is $419. After day 90, lifetime reserve days can be used, each incurring a coinsurance of $838 per day.

Medicare Part B services are subject to an annual deductible. In 2025, the Part B annual deductible is $257. After this deductible is met, beneficiaries pay 20% of the Medicare-approved amount for most Part B-covered services. This 20% is known as coinsurance.

Outpatient hospital services, even if covered by Part B, may involve copayments that vary by service. Observation services are billed under Part B and can result in multiple copayments, potentially exceeding the Part A inpatient deductible. To manage out-of-pocket costs with Original Medicare, some beneficiaries purchase a Medicare Supplement Insurance (Medigap) policy. These private plans can help cover deductibles, coinsurance, and copayments not covered by Original Medicare.

Medicare Advantage Plan Coverage

Medicare Advantage Plans (Part C) offer an alternative way to receive Medicare benefits through private insurance companies. These plans must provide at least the same coverage as Original Medicare (Parts A and B). Therefore, if a kidney stone removal procedure is covered under Original Medicare, it must also be covered by a Medicare Advantage Plan.

While Medicare Advantage Plans must cover the same services, they often have different cost-sharing structures. These plans have their own deductibles, copayments, and coinsurance amounts for various services. Costs can vary significantly between different plans and providers.

Many Medicare Advantage Plans operate with provider networks, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). Beneficiaries may be required to use in-network providers for the highest level of coverage. Seeking care outside the network could result in higher out-of-pocket costs or no coverage. Some plans also require referrals or prior authorization for certain procedures, including kidney stone removal treatments.

Factors Influencing Coverage Decisions

Several factors influence Medicare coverage for kidney stone removal. The primary consideration is medical necessity. Medicare defines medically necessary services as those reasonable and necessary to diagnose or treat an illness or injury and meet accepted medical standards.

Another important factor is whether the healthcare provider and facility accept Medicare assignment. When a provider accepts assignment, they agree to accept the Medicare-approved amount as full payment for covered services. This limits the beneficiary’s charges to the Medicare deductible and coinsurance. Most providers who treat Medicare beneficiaries accept assignment.

Prior authorization or referrals may be required for certain procedures or specialist visits, particularly with Medicare Advantage Plans. While Original Medicare generally does not require prior authorization for most services, some outpatient procedures may need prior approval. Medicare Advantage Plans frequently require prior authorization for a wider range of services, including certain surgeries or hospital stays.

The place where the service is rendered also impacts coverage and costs. Whether a kidney stone removal procedure is performed in an inpatient hospital setting or an outpatient ambulatory surgical center determines if Part A or Part B coverage applies, and thus, the associated deductibles and coinsurance. The classification of a hospital stay as “inpatient” versus “observation status” is significant; observation services are outpatient care covered under Part B, leading to different cost-sharing than a Part A inpatient admission.