Does Medicare Cover Lithotripsy for Kidney Stones?

Lithotripsy uses shockwaves to break down kidney stones into smaller pieces, allowing them to pass more easily from the body. Given the frequency of kidney stone issues, many individuals wonder about Medicare’s role in covering this treatment. Medicare generally covers medically necessary lithotripsy, recognizing it as an effective way to address kidney stones. Coverage specifics, including patient costs, depend on factors such as the setting where the procedure is performed and the type of Medicare plan an individual has.

Medicare Part B Coverage for Lithotripsy

Medicare Part B is the component of Original Medicare that covers outpatient medical services and supplies. This includes doctor’s services, outpatient hospital care, and services provided at ambulatory surgical centers. Lithotripsy is most often performed in an outpatient setting, making Part B the primary payer for these procedures.

Under Part B, once the annual deductible is met, Medicare generally pays 80% of the Medicare-approved amount for covered services. For 2025, the Part B deductible is $257. This means the beneficiary is responsible for the remaining 20% coinsurance. Both the facility where the lithotripsy is performed and the physician’s services will have separate charges, subject to these Part B cost-sharing rules.

Coverage for lithotripsy under Part B is contingent on the procedure being deemed medically necessary by a healthcare provider. If the procedure is not considered medically necessary, Medicare will not provide coverage.

Medicare Part A Coverage Considerations

While less common for lithotripsy, Medicare Part A covers inpatient hospital care. If lithotripsy requires an inpatient hospital admission, Part A would cover the hospital portion of the bill.

Part A has a deductible for each benefit period, which is $1,676 in 2025. Once this deductible is satisfied, Part A generally covers the hospital costs for the first 60 days of an inpatient stay. Even if lithotripsy is performed during an inpatient admission covered by Part A, the professional services provided by the physician for the procedure would still typically fall under Medicare Part B.

Understanding Your Out-of-Pocket Costs

Original Medicare beneficiaries are responsible for certain out-of-pocket costs, including deductibles and coinsurance. For lithotripsy performed in an outpatient setting, the Part B deductible must be met, followed by a 20% coinsurance. If the procedure necessitates an inpatient hospital stay, the Part A deductible would apply for the hospital portion of the bill.

Medicare Advantage Plans, also known as Part C, offer an alternative way to receive Medicare benefits. These plans must cover at least what Original Medicare covers, including lithotripsy. However, they may have different cost-sharing structures, such as copayments, deductibles, and annual out-of-pocket limits. Medicare Advantage plans can also have specific networks of providers and may require prior authorization for certain services. Individuals with a Medicare Advantage plan should review their specific plan documents to understand their financial responsibilities.

For those with Original Medicare, Medigap (Medicare Supplement Insurance) plans can help cover some of these out-of-pocket costs. Medigap policies are designed to pay for expenses like Part A and Part B deductibles, coinsurance, and copayments. However, Medigap plans do not work with Medicare Advantage plans; they are only for beneficiaries with Original Medicare. Costs can also arise from services not covered by Medicare or from providers who do not accept Medicare assignment.

Navigating the Coverage Process

To ensure lithotripsy is covered, a physician must determine the procedure is medically necessary based on diagnostic tests and the patient’s specific condition. Medicare defines medical necessity as services or supplies that are reasonable and necessary to diagnose or treat an illness or injury, meeting accepted standards of medical practice. A clear doctor’s order for the procedure is a foundational requirement for coverage.

Patients should confirm that their chosen doctor and facility accept Medicare assignment. When a provider accepts Medicare assignment, they agree to accept the Medicare-approved amount as full payment for covered services. This means they cannot charge the beneficiary more than the Medicare deductible and coinsurance amounts.

Some procedures, especially under Medicare Advantage plans, may require prior authorization from the plan before the service is rendered. Patients should always check with their plan or healthcare provider to determine if prior authorization is needed to avoid unexpected costs. After the procedure, reviewing the Medicare Summary Notice (MSN) or the Explanation of Benefits (EOB) from a Medicare Advantage plan can help individuals understand what was billed and covered.