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Does Medicare Require Prior Authorization for Surgery?

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require prior authorization doctors looking at laptopMedicare 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?

prior approval medicare writing an informationMedicare 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.




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?

medicaid services doctor taking a phonecallThe 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

services requiring prior authorization paper handed overYou 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.

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How To Obtain Prior Authorization from Medicare?

medical necessity doctors talkingGo to the Medicare website to find your health plan information. You can also review the document you got when you enrolled in the Medicare healthcare program. Check whether you require prior authorization for your medical surgery or not. You can also contact your health insurer if you’re still in doubt or need prior approval.

Get the request form and fill it out carefully to submit your prior authorization request. Enter accurate and thorough information in the form. Double-check all the information before you submit your request to Medicare.

Your health insurer will review your prior approval request and revert with their response. However, if Medicare refuses your request, but your healthcare provider believes this surgery is medically obligatory, they may approach Medicare and request an exception.

Your healthcare provider must support your request with a valid statement to force Medicare to review your request again. If Medicare finds your request for a certain surgery medically necessary, they may approve your prior approval request as an exceptional case. 

How Much Time Does the Prior Authorization Process Take?

medicare approved doctor writingYour prior approval request may get approved within a week or may take a month for approval, depending on the complexity of your prescribed medical surgery. Your clinical data and other information shared by the healthcare provider play a vital role in the processing speed of your prior authorization request.

Your request may get approved or refused based on your Medicare’s health plan criteria. Also, if the data sent by the healthcare provider to Medicare covers everything they need for review, your prior approval request may get processed speedily.

Navigating Medicare: Understanding Prior Authorization

prior authorization doctor showing documentationServices Requiring Prior Authorization: Many medical services, especially specific surgeries such as rhinoplasty, vein ablation, and breast surgery, necessitate prior authorization from Medicare. This proactive step ensures that essential and medically necessary care is prioritized.

Prior Authorization Requests: Submitting prior authorization requests is a crucial aspect of the Medicare process. Healthcare providers initiate this process by seeking approval from Medicare before commencing certain medical treatments. Patients are advised to be aware of the need for prior authorization to prevent potential issues with coverage and billing.

Understanding the intricacies of prior authorization requests is essential for patients navigating the Medicare system. The timely submission of accurate and comprehensive information is pivotal in expediting the approval process and ensuring coverage for prescribed medical procedures.

Durable Medical Equipment: Certain medical facilities, such as durable medical equipment or prosthetics, may require prior authorization. Patients using Medicare Part A or Part B should be aware of these requirements to guarantee coverage for necessary equipment.

Hospital Outpatient Department: For medical procedures conducted in a hospital outpatient department, prior authorization may be necessary. Patients seeking services in this setting should be attentive to the prior authorization requirements to avoid any complications with billing.

Medicare Advantage Plan: Enrolled individuals in a Medicare Advantage plan may encounter prior authorization requirements for certain medical procedures. Understanding the specific guidelines of their Medicare Advantage plan is essential for seamless healthcare coverage.

When enrolled in a Medicare Advantage plan, members should be aware that certain medical facilities, specialists, or out-of-network providers may require prior authorization. Proactive communication with the healthcare provider and adherence to prior authorization requests is vital for financial coverage.

Medicare Services: Navigating the landscape of Medicare services requires understanding the nuances of prior authorization. This proactive approach ensures that individuals receive the necessary approvals for their medical treatments and services, preventing potential out-of-pocket expenses.

Medical procedures and services that are Medicare-approved are typically pre-authorized. However, patients should still confirm coverage details with their health insurance provider to ensure that all aspects of their healthcare needs are addressed.

While the article primarily focuses on Medicare, it’s important to note that Medicaid services may also have their own set of prior authorization requirements. Individuals eligible for both Medicare and Medicaid should be aware of the specific guidelines for each program.


This informative article sheds light on the intricacies of the Medicare system, with a particular focus on the prior authorization process and the necessity of prior approval for specific medical procedures. The importance of understanding one’s Medicare Advantage plan requirements is emphasized, ensuring that individuals are aware of the instances where prior authorization is crucial. The article also briefly touches upon Medicare assignment and the role of the Social Security Act, providing a holistic perspective on navigating the complexities of Medicare. By highlighting the need for proactive communication, accurate information submission, and awareness of coverage nuances, the article serves as a valuable guide for individuals seeking clarity within the Medicare landscape.

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