Hernias are a common medical condition that can cause discomfort, pain, and complications if left untreated. For individuals enrolled in Medicare, understanding whether hernia surgery is covered — and what out-of-pocket costs to expect — is essential. In this article, we’ll break down Medicare coverage for hernia surgery, what’s required, and how much it may cost.
Does Medicare Cover Hernia Surgery?
Yes, Medicare typically covers hernia surgery when it is medically necessary.
Medicare Part B, which covers outpatient services, generally pays for hernia repairs performed in outpatient surgical centers or doctor’s offices. If the procedure requires hospitalization, Medicare Part A may cover the inpatient hospital stay.
Medicare will cover open hernia repair, laparoscopic hernia surgery, or robotic-assisted procedures, provided your doctor deems the surgery medically necessary to treat pain, discomfort, or health complications caused by the hernia.
What Types of Hernia Surgeries Does Medicare Cover?
Medicare may cover the following hernia surgeries:
- Inguinal hernia repair (groin area)
- Umbilical hernia repair (belly button area)
- Incisional hernia repair (from a previous surgery incision)
- Hiatal hernia repair (upper stomach area)
Does Medicare Require Prior Authorization for Hernia Surgery?
In general, Original Medicare (Part A and Part B) does not require prior authorization for hernia surgery. However, if you have a Medicare Advantage plan (Part C), the rules may differ. Many Medicare Advantage plans do require prior authorization before approving coverage for surgery. Always check with your plan provider to confirm whether prior authorization is needed.
How Much Does a Hernia Operation Cost with Medicare?
Original Medicare Costs
If the surgery is performed in an outpatient setting, Medicare Part B covers 80% of the approved cost after you meet your annual deductible. You are responsible for:
- 20% coinsurance
- Part B deductible (in 2025, the deductible is $240)
If you are admitted to a hospital for the surgery, Medicare Part A will cover inpatient costs, but you’ll be responsible for:
- Part A deductible (in 2025, the deductible is $1,632 per benefit period)
- Potential daily copayments for extended hospital stays
Medicare Advantage Costs
With a Medicare Advantage plan, your copayments, coinsurance, and deductibles will vary depending on your specific plan. Many plans have fixed copays for outpatient surgeries, but prior authorization requirements may apply.
How Long is the Waiting List for a Hernia Repair?
Medicare and Surgery Scheduling
Medicare does not directly impose waiting periods for surgeries like hernia repairs. However, waiting times depend on your location, your surgeon’s availability, and the urgency of your condition. In most cases, if your hernia is causing severe symptoms, surgery can be scheduled relatively quickly.
Patients enrolled in Medicare Advantage plans may experience slightly longer wait times if prior authorization is required.
How Does a Doctor Determine If You Need Hernia Surgery?
Your doctor will typically evaluate several factors before recommending hernia surgery, including:
- The size of the hernia
- Your symptoms (pain, discomfort, digestive issues)
- The risk of complications, such as strangulation or obstruction
- Your overall health and medical history
If your hernia is small and asymptomatic, your doctor may recommend watchful waiting rather than immediate surgery. However, if the hernia grows, becomes painful, or poses a health risk, surgery may become necessary.
Conclusion
Does Medicare Cover Hernia Surgery? Yes — When Medically Necessary.
Medicare provides coverage for hernia surgery when deemed medically necessary, whether performed in a hospital (covered by Part A) or in an outpatient center (covered by Part B). Beneficiaries with Medicare Advantage plans should check for prior authorization requirements and review their specific cost-sharing details.
If you’re considering hernia surgery and want to understand your Medicare coverage, speak with your healthcare provider and contact Medicare or your Medicare Advantage plan to confirm your benefits.
Frequently Asked Questions (FAQs)
1. Does Medicare cover laparoscopic hernia surgery?
Yes, Medicare covers laparoscopic hernia surgery when it’s medically necessary.
2. Will I need to pay anything out-of-pocket for hernia surgery with Medicare?
You’ll generally pay 20% coinsurance under Part B for outpatient procedures after meeting the deductible. Hospital stays under Part A have their own cost-sharing rules.
3. Can a Medicare Advantage plan deny hernia surgery?
A Medicare Advantage plan could deny coverage if prior authorization is not obtained or if the surgery is deemed not medically necessary. Always check with your plan provider.
Optimize Your Medicare Coverage for Surgery
If you want help finding a Medicare Advantage plan that covers hernia surgery with low out-of-pocket costs, speak to a licensed Medicare advisor today.
