Does Medicare Cover Prostate Surgery?
Original Medicare covers prostate surgery, including preparation and follow-up care. The procedure you’re having and where it takes place determines how much is covered and what you’ll pay.
Original Medicare, specifically Part B, covers medically necessary prostate surgeries and procedures. This includes treatments for an enlarged prostate to relieve symptoms and improve urinary flow as well as treatments for prostate cancer.
Covered prostate procedures include:
removal of cancerous growths from the prostate (along with follow-up radiation therapy, chemotherapy, immunotherapy, or other cancer treatments)
complete removal of prostate gland
partial removal of prostate gland
removal (ablation) of prostate tissue to shrink the gland
This article reviews the prostate surgeries Medicare covers and what you’ll pay.
What prostate surgical procedures are covered by Medicare?
Medicare covers the following types of prostate procedures:
Radical prostatectomy: removal of the entire prostate gland and some of the surrounding tissues; nearby lymph nodes may be removed as well
Open prostatectomy (open surgery): removal of enlarged prostate tissue via one large incision
Laparoscopic prostatectomy: removal of enlarged prostate tissue via four small incisions
Transurethral resection of the prostate (TURP): removal of portions of the prostate that affect urine flow
Transurethral incision of the prostate (TUIP): small cuts made to the prostate to reduce pressure on the urethra and improve urinary flow
Medicare also covers ablation. Ablation involves different techniques to remove dead or excess prostate tissue, which shrinks the gland and provides symptom relief and better urinary flow. Covered ablation techniques include:
Radiofrequency generated water vapor thermotherapy: uses water vapor thermotherapy
Laser vaporization: uses a green-light laser
Cryosurgical ablation: uses extremely cold temperatures
Is robotic surgery covered by Medicare?
Procedures to remove the prostate (prostatectomies) may be open, laparoscopic, or robot-assisted. Medicare covers all three types as long as they’re medically necessary.
Reimbursement for robot-assisted prostatectomies is the same as for traditional (laparoscopic) prostatectomies.
How much does prostate surgery cost with Medicare?
The table below provides the national average costs for prostate procedures based on Medicare’s 2024 payments and copayments. Costs include facility and doctor’s fees. If you need more than one doctor, additional costs may apply.
When first discussing your procedure with your doctor, be sure to ask about your costs and surgical options, including where the procedure will take place, as this will affect the price you pay.
Procedure | Ambulatory surgical center: What you’ll pay | Hospital outpatient departments: What you’ll pay |
|---|---|---|
$636 | $1,128 | |
$629 | $1,121 | |
$573 | $1,065 | |
Transurethral destruction of prostate tissue by radiofrequency generated water vapor thermotherapy | $356 | $739 |
$418 | $757 | |
$655 | $1,147 | |
$1,454 | $1,781* |
*Original Medicare caps your copayments at $1,632. This likely applies to cryosurgical ablation of the prostate.
Does Medicare pay for diagnosis and imaging scans?
Diagnostic tests look for changes in your health and help your doctor identify suspected health conditions.
Medicare Part B covers diagnostic laboratory tests when your doctor orders them, and they’re considered medically necessary. These tests include:
blood tests
urinalysis
tissue specimens testing
screening exams
Medicare typically covers all doctor-ordered diagnostic laboratory tests. You pay nothing.
Does Medicare cover prostate cancer screening?
Medicare Part B covers digital rectal exams and prostate-specific antigen (PSA) blood tests once a year if you’re over 50 years old. Coverage starts the day after your 50th birthday.
What you will pay for prostate screenings
For digital rectal exams: After you meet your Part B deductible, you will pay 20% of the Medicare-approved amount for a once-yearly exam, plus your doctor’s services associated with the exam. If the exam is done in a hospital setting, you will also need to pay a separate hospital visit copayment.
For PSA blood test: You pay nothing for a yearly PSA test as long as your doctor has accepted the Medicare assignment.
What is a Medicare assignment?
A Medicare assignment is an agreement signed by your doctor or another healthcare professional that confirms:
they will be paid directly by Medicare
they accept the Medicare-approved billing amount for the service
they agree not to bill you for anything over the Medicare deductible and coinsurance amounts
Do Medicare Advantage plans cover prostate surgeries?
Medicare Advantage plans are an alternative to Original Medicare. They’re offered by private, Medicare-approved insurance companies.
Medicare Advantage plans offer the same hospital and medical insurance as Original Medicare (parts A and B), plus additional benefits like dental services, vision, and hearing care. Most Medicare Advantage plans also include drug coverage.
This means prostate surgery will likely be covered by a Medicare Advantage Plan. However, the exact coverage and cost depend on your plan.
Types of Medicare Advantage plans
You can choose from the following types of Medicare Advantage plans:
Health Maintenance Organization (HMO): HMO plans use in-network doctors and require referrals for specialists.
Preferred Provider Organization (PPO): PPO plans charge different rates based on in-network or out-of-network services.
Private Fee-for-Service (PFFS): PFFS plans are special payment plans that offer your healthcare professional more flexibility.
Special Needs Plans (SNPs): SNPs help with long-term medical costs for chronic conditions.
Medical Savings Account (MSA): MSA plans are medical savings accounts paired with high deductible health plans.
You can use this table from Medicare to compare types of Medicare Advantage plans and what they cover.
Learn more about Medicare Advantage plans.
Takeaway
Original Medicare (parts A and B) helps cover medically necessary prostate surgeries. The exact cost and coverage depend on the type of surgery you’re having and whether it’s being done in an inpatient or outpatient setting.
Most Medicare Advantage (Part C) plans also cover the cost of prostate surgeries and procedures. The cost and coverage depend on your plan, the type of surgery, and where it’s being done.
Talk with your doctor about your treatment options and what Medicare may or may not cover.
You can also call 800-MEDICARE (800-633-4227) to talk with a real person, 24 hours a day, 7 days a week. They can help answer any questions you may have about your coverage and costs for prostate surgery.
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