Is Laser Surgery Covered by Medicare?

Medicare provides health coverage for millions of Americans, and a question concerns its coverage of laser surgery. While Medicare covers some laser surgeries, this coverage is not universal. Specific conditions and medical necessity criteria determine whether a particular laser procedure receives coverage.

General Medicare Coverage for Medical Procedures

Medicare’s coverage for medical procedures, including laser surgeries, relies on the concept of “medically necessary” services. A service is medically necessary if it is needed to diagnose or treat an illness, injury, condition, or disease, and meets accepted medical practice standards. The Centers for Medicare & Medicaid Services (CMS) establishes national guidelines for medically necessary services, ensuring covered services are proper and needed for a beneficiary’s medical condition.

For coverage to apply, procedures must be performed by doctors, hospitals, or outpatient facilities that accept Medicare. Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), covers medically necessary surgeries. Part A typically handles inpatient surgeries and hospital stays, while Part B covers outpatient surgeries and related services.

Specific Laser Procedures Covered by Medicare

Medicare covers laser procedures when medically necessary to treat a specific health condition. Laser-assisted cataract surgery, for instance, is covered when performed to remove cataracts that impair vision. Medicare Part B covers the surgical procedure, including the removal of the cataract and the implantation of a standard intraocular lens. While standard lenses are covered, beneficiaries may pay extra for premium or multifocal lenses that offer additional vision correction, as these are not considered medically necessary.

Laser treatments for glaucoma are also covered when medically necessary to manage the condition. Procedures such as Selective Laser Trabeculoplasty (SLT), Argon Laser Trabeculoplasty (ALT), and Laser Peripheral Iridotomy (LPI) fall under this category. These interventions aim to reduce intraocular pressure and prevent further vision loss due to glaucoma. Coverage is provided when these procedures are part of a treatment plan for a diagnosed glaucoma condition.

Laser prostate surgery, including GreenLight Laser Photoselective Vaporization of the Prostate (PVP) and Holmium Laser Enucleation of the Prostate (HoLEP), is covered for benign prostatic hyperplasia (BPH) when medically necessary. These procedures address symptoms such as frequent urination and poor urinary flow that have not responded to medical therapy.

Additionally, Medicare covers laser removal of precancerous or cancerous skin lesions. Certain laser procedures for cardiovascular conditions may also be covered if they are determined to be medically necessary for diagnosis or treatment.

Laser Procedures Not Covered by Medicare

Medicare does not cover laser procedures considered elective, cosmetic, or experimental. Refractive eye surgeries, such as LASIK (Laser-Assisted In Situ Keratomileusis) and PRK (Photorefractive Keratectomy), are typically not covered. These procedures are designed to correct vision and reduce reliance on glasses or contact lenses, which Medicare considers an elective improvement rather than a medically necessary treatment for an illness or injury.

Cosmetic laser procedures aimed solely at improving appearance are also excluded from Medicare coverage. This includes treatments for wrinkles, hair removal, or tattoo removal. The distinction hinges on whether the procedure addresses a functional impairment or a diagnosed medical condition.

Experimental or investigational laser therapies are generally not covered by Medicare. New medical technologies and procedures must undergo rigorous review and be widely recognized as safe and effective before they are considered for Medicare coverage. If a laser treatment is still in the trial phase or lacks sufficient evidence of its effectiveness and safety, Medicare will typically not provide coverage.

Understanding Costs and Supplemental Coverage

Even for covered laser surgeries, beneficiaries are responsible for certain out-of-pocket costs under Original Medicare (Parts A and B). For outpatient procedures, which many laser surgeries are, Medicare Part B typically covers 80% of the Medicare-approved amount after the annual deductible is met. The beneficiary is responsible for the remaining 20% coinsurance. In 2024, the Part B deductible is $240. For inpatient stays covered by Part A, a deductible applies per benefit period, which is $1,632 in 2024.

Medicare Advantage (Part C) plans offer an alternative way to receive Medicare benefits and must cover at least what Original Medicare covers. These plans are provided by private insurance companies and often have different cost-sharing structures, including copayments, deductibles, and out-of-pocket maximums. Specific costs and coverage details for laser surgery can vary significantly between plans. Beneficiaries should review their plan documents carefully to understand their financial responsibilities.

Medigap, or Medicare Supplement Insurance, plans help cover some of the out-of-pocket costs left by Original Medicare, such as deductibles, copayments, and coinsurance. These plans work alongside Original Medicare, paying after Original Medicare has paid its share. For example, a Medigap plan could cover the 20% coinsurance for a covered outpatient laser surgery, reducing the beneficiary’s direct cost.

Medicare Part D provides prescription drug coverage. While Part D does not cover the laser surgery itself, it may cover prescription medications needed before or after a procedure, such as eye drops following cataract surgery. Beneficiaries with Medicare Advantage plans often have Part D coverage bundled into their plan.

Steps for Confirming Coverage and Addressing Denials

Before undergoing any laser surgery, it is advisable to confirm coverage with both the healthcare provider and Medicare or your Medicare Advantage plan. Healthcare providers can verify coverage and discuss potential out-of-pocket costs. For some procedures, especially with Medicare Advantage plans, pre-authorization may be required to ensure coverage. Without proper pre-authorization, a plan might deny coverage, leaving the patient responsible for the full cost.

Beneficiaries should understand the Advance Beneficiary Notice of Noncoverage (ABN). An ABN is a written notice from a provider informing a beneficiary that Medicare may not pay for a specific service or item. By signing the ABN, the beneficiary acknowledges that they may be responsible for payment if Medicare denies the claim. This notice is typically issued for services that Medicare might not consider medically necessary or that exceed frequency limits.

If Medicare denies coverage for a laser surgery, beneficiaries have the right to appeal the decision. The appeals process involves several levels, starting with a redetermination by a Medicare Administrative Contractor. Subsequent levels include reconsideration by a Qualified Independent Contractor and a hearing before an Administrative Law Judge.

Resources like State Health Insurance Assistance Programs (SHIPs) can provide personalized, unbiased guidance on Medicare questions, including coverage and appeals. SHIPs offer free counseling services to help beneficiaries understand their options and navigate the complexities of Medicare.