My doctor mentioned something about Medicare not covering my procedure. How do I find out for sure before I get stuck with a bill?

Question

Larry Dalton · Accepted Answer

Suppose you're under Medicare Part A and Part B with a Medicare supplemental insurance, and the physician sees a need for a diagnosis due to your health circumstances. In that case, the procedure should be covered, less any amounts for Medicare Part B premium or deductibles, and this is based on the type of supplemental plan you have. If you're on Medicare Part A and B with a Medicare Part C - Advantage plan, then your coverage could only be determined with the prior approval procedure through the insurance carrier of your Advantage plan. Most likely, there will be additional deductibles, co-pays, or out-of-network charges under these plans.

Answered by Larry Dalton on April 3, 2025

Broker Licensed in OK & TX

Answered by Larry Dalton Medicare Insurance Agent

Lt Col Tim Brown · Answer

You can contact your insurance company and ask. Get the persons name you talk to, phone, badge number if it applies and the date and time of your call. You can go onto Medicare.gov and search there too. You can contact the billing department of your doctors office and ask. They bill insurance and know what they pay on or don’t. Hope that helps.

Answered by Lt Col Tim Brown on April 16, 2025

Broker Licensed in TN, AL, CO & 10 other states

Answered by Lt Col Tim Brown Medicare Insurance Agent

William Lawler · Answer

The best way to find out if Medicare will cover your procedure is by contacting your agent. If you don`t have an agent, contact CMS. If you have an Advantage plan or Medigap plan, contact their member services.

Answered by William Lawler on May 9, 2025

Broker Licensed in MO, FL, IA & 12 other states

Answered by William Lawler Medicare Insurance Agent

Deborah Lee · Answer

Contact the billing department of your Clinic or Hospital and talk to the billing representative, and ask them.

Steven Bleicher · Answer

The only healthcare procedures that are NOT covered are those of an experimental nature. However, once the CDC checks out these types of treatments, as long as it meets the quirky Federal guidelines, it may be declared to be covered. Be advised that there are over 60,000 treatments that are currently covered by Medicare. Your doctor was being honest with you and the odds are that most of the "uncovered" treatments are those recommended by a chiropractor since they can (via trial-and-error) attempt to develop a procedure that she/he successfully worked with "some" of their patients. Your best double-check is always to call 1-800-MEDICARE and the reps should be able to sanction a procedure unless it is brand new and has yet to be tested.

Answered by Steven Bleicher on April 5, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Nancy Suozzi-Vidal · Answer

Determine why the doctor is stating this… typically certain criteria need to be met; prior authorization typically required so you can know in advance if approved or not; 
If Medicare is primary, get specific procedure codes from provider’s biller and contact Medicare; 
If Medicare Advantage, you can discuss with your carrier reason for denial and determine what further info needs to be submitted by your doctor

Fred Manas · Answer

It's wise to check on Medicare coverage before a procedure, especially if your doctor has raised concerns. 
Here's how you can verify if Medicare will cover your upcoming procedure:
1. Check Medicare's Website:
Go to Medicare.gov's "What's Covered" tool and search for your specific procedure.
You can also download the "What's Covered" mobile app for easy access on the go. 
2. Talk to your Doctor or their Billing Department:
Your doctor's office might have experience with similar procedures and can offer insights.
They can also clarify the medical coding for the procedure, which affects coverage. 
3. Contact Medicare Directly:
Call 1-800-MEDICARE and explain your situation.
They can provide information on Medicare coverage and your potential out-of-pocket costs. 
4. Review your Medicare Summary Notice (MSN):
If the procedure is similar to something you've had in the past, look at your past MSNs.
This can give you an idea of how similar procedures were covered previously. 
5. Consider a Pre-Authorization:
In some cases, you can request a pre-authorization from Medicare to confirm coverage before the procedure.
This can provide peace of mind and avoid unexpected bills later. 
Important Note:
Keep records of all your inquiries, including names of representatives you spoke with and dates of contact.
If your doctor suggests that Medicare might not cover the procedure, they may ask you to sign an Advance Beneficiary Notice of Noncoverage (ABN), acknowledging that you'll be responsible for the cost if Medicare denies the claim.
If you have a Medicare Advantage plan, consult your plan materials or contact your plan directly to confirm coverage and cost-sharing details.

Gary Henderson · Answer

Have a predetermination submitted to see if it is covered. 
You can find many answers for Medicare supplement plans in the Medicare guide and website 
Medicare advantage plans require you to be contact your insurance company

Vachik Chakhbazian · Answer

To ensure your procedure is covered by Medicare before incurring unexpected costs, you should first ask your doctor or the facility if they accept Medicare and if they will accept assignment. You can also verify coverage on the Medicare.gov website . If coverage is uncertain, inquire about potential out-of-pocket costs and ask if the provider will file a claim with Medicare, even if they anticipate a denial.

Answered by Vachik Chakhbazian on April 11, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Deborah Webster · Answer

Contact the carrier you have for your Medical coverage, or refer to your evidence of coverage on your policy. If all you have is original Medicare, you may call 1-800-Medicare for more information.

Sonya Chandler · Answer

Ask your doctor to submit a pre-determination of benefits to the insurance company or Medicare prior to performing the procedure. You can also call Medicare or the insurance company with the procedure code provided by your doctor and ask if it's covered.

Answered by Sonya Chandler on May 21, 2025

Agent Licensed in NY, AZ, FL & 5 other states

Answered by Sonya Chandler Medicare Insurance Agent

Wild Bill Anderson · Answer

Call us about your plan and we can tell you or tell you who can. Knowing we are here for you is a valuable resource.

Robert Barco · Answer

Original Medicare will not pay for certain things, like physical exams, cosmetic surgery, dental, vision, or hearing aids. Original Medicare and Medicare Advantage plans will both require prior authorizations before any major procedures are done. These requests for prior authorizations are the responsibility of the doctor and or hospital to obtain before medical procedures start.

Answered by Robert Barco on April 22, 2025

Broker Licensed in OH

Answered by Robert Barco Medicare Insurance Agent

Melanie Blackston · Answer

You will need to call your insurance companies customer service and check the specific deductible, co-pays and benefits of your plan for your procedure.

Britania James · Answer

Speak with the billing office at your doctor's office. As an agent, I'm always happy to assist you with speaking directly with your insurance carrier further.

My doctor mentioned something about Medicare not covering my procedure. How do I find out for sure before I get stuck with a bill?

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My doctor mentioned something about Medicare not covering my procedure. How do I find out for sure before I get stuck with a bill?

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