Does Medicare Require Prior Authorization for Surgery?

Medicare is a US health insurance program designed for people aged 65 or more. Like a private health insurance company, it requires prior authorization for certain medical procedures. Many general medical facilities are pre-approved, while various surgeries, like rhinoplasty, vein ablation, etc., need prior approval.

Medicare has different health plans with several medical benefits that allow its enrolled members to utilize their healthcare plan when needed. However, you must get approval from the US state health insurer before taking any certain medical treatment. You’ll have to pay your entire bill if you don’t get a prior authorization approval.

This article will share about Medicare prior authorization, how it works, what types of surgeries require prior authorization, and how to obtain prior approval for medical surgery.

What Does Medicare Prior Authorization Mean?

Medicare prior authorization refers to the management process in which a Medicare-enrolled member requests prior approval to obtain a certain medication or medical necessity from Medicare.

For instance, you encountered an injury and went to the doctor for medical care. The healthcare provider prescribed a certain medical procedure. Before he starts your treatment, he must submit a request to Medicare for prior approval.

However, suppose your healthcare provider fails to submit a prior authorization request. In that case, your health insurance company won’t pay for your medical expenses, and you’ll have to pay your entire bill yourself.

How Does Medicare Prior Authorization Work?

Medicare prior authorization operates in a similar way to what a private health insurer does. Below are some critical steps of how Medicare prior authorization works.

For instance, you visit a doctor for medical treatment. The healthcare provider prescribes a certain medical procedure to cure your illness. However, you or your healthcare provider must obtain prior approval before starting your treatment to ensure your Medicare pays for your medical expenses.

Your healthcare provider submits a prior authorization request to Medicare, who reviews your request for a certain medical treatment. Based on the shared information and clinical data, they decide whether to approve or reject your prior approval request.

However, if Medicare finds your prior authorization request qualifies the health plan criteria, they’ll approve your request for a particular medication or medical necessity. Conversely, your insurance provider may reject your request if it meets the health plan requirements. You may directly request Medicare or ask your healthcare provider to talk to review their decision if they deny approving your prior authorization request.

Why Medicare Often Require Prior Authorization?

Medicare demands prior authorization for certain medical surgeries for many reasons. One main reason is to prioritize medically necessary care. Prior authorization lets health insurers review the prior approval request to ensure the prescribed medical procedure is necessary before approving it.

Prior authorization ensures that the patients who require urgent care obtain prior approval only. It also helps to keep Medicare’s medical expenses down. Prior authorization ensures you get prior approval from your healthcare insurance company before you obtain certain medical care. It prevents you from the risk of paying the entire bill yourself if your request gets refused on late submission.

Medical Surgeries That Require Medicare Prior Authorization Request?

The situations in which you’ll need to submit a Medicare prior authorization can vary per your health plan guidelines. However, certain surgeries will likely need prior approval. Medicare requires prior authorization for following medical surgeries.

Blepharoplasty

Rhinoplasty

Panniculectomy

Implanted spinal neurostimulators

Bariatric surgery

Botulinum toxin injections

Endoscopic procedures for reflux management

Cervical fusion with disc removal

Breast surgery

Orthognathic surgery

Vein ablation

How Do I know if I require Medicare Prior Authorization?

The best way to know if you require Medicare prior authorization is by contacting your health insurance company. When you enroll for a Medicare health plan, you get a paper that lists all medical facilities for which you don’t need prior approval. You can read that document to check if you have prior approval for your prescribed medical treatment or medication. Also, you can contact your healthcare insurer’s website to know whether you require prior authorization.

Suppose you have a Medicare Part A or Part B health plan. In that case, you’re less likely to need prior authorization for your medical service as many medical facilities are pre-approved beforehand by Medicare. However, you must still confirm with your health insurance provider to ensure they cover all your medical expenses. Durable hospital equipment or prosthetics are a few medical facilities that require prior approval.

Medicare Part C (for medical procedures) and Medicare Part D (for pharmaceuticals) occasionally need prior authorization. Medicare Part C (also known as Medicare Advantage) asks your healthcare provider to obtain approval before they give you certain medical treatment. Likewise, Medicare Part D requires you to get prior authorization approval from Medicare for a prescribed pharmaceutical drug.

Medicare Advantage Prior Authorization

You must submit a prior authorization request to obtain any medical facility from a specialist, out-of-network healthcare provider, or emergency care provider as an enrolled Medicare Advantage (MA) plan member. Even though it provides prior approval for many medical facilities, it’s essential to check with your health insurer and, if required, submit a request to avoid any problems later. If Medicare denies your prior approval request, your MA plan won’t cover your medical expenses, and you’ll need to pay your bills yourself.

Your healthcare provider doesn’t need prior approval for general medical procedures for general medical procedures as they are already pre-approved in advance in your Medicare Advantage plan. However, you must submit a prior approval request for certain medical surgeries like rhinoplasty.

Every Medicare health plan provides several medical facilities. You must know which medical facilities your health plan can cover as an enrolled member. 

You can contact your health insurance company to understand your healthcare plan. A good understanding can help you decide if you require prior authorization for a certain medical surgery.