Medicare is the federal health insurance program for individuals aged 65 or older, as well as certain younger people with disabilities. A common question is whether this program covers advanced treatments like laser surgery. Coverage for any procedure, including those involving laser technology, ultimately depends on whether the service is considered medically necessary. The use of a laser, which is merely a type of surgical tool, does not automatically qualify or disqualify a procedure for coverage.
The Core Rule: Coverage Based on Medical Necessity
The foundational principle governing Original Medicare coverage is that the service must be medically necessary. This means the procedure must be required to diagnose or treat an illness, injury, condition, or the function of a malfunctioning body part. If a procedure is deemed purely elective or cosmetic, Medicare will not cover it, regardless of the technology used.
The technology employed, whether a traditional scalpel or a focused laser beam, is secondary to the purpose of the treatment. For example, a laser procedure to remove a tumor is treated differently than a laser procedure to smooth wrinkles. A physician must demonstrate that the laser surgery is an accepted, effective, and appropriate treatment for a diagnosed medical condition.
Common Laser Surgeries Medicare Does Cover
Many laser procedures are covered because they meet the medical necessity standard by treating serious conditions. These typically fall under Medicare Part B, which covers outpatient medical services and physician fees.
One of the most common covered laser procedures is cataract surgery, where a laser may be used to make precise incisions or soften the cloudy lens before removal. Medicare Part B covers the removal of the cataract and the implantation of a standard intraocular lens because the procedure restores vision impaired by disease. Similarly, laser treatments for glaucoma, such as Selective Laser Trabeculoplasty (SLT), are covered because they treat a progressive disease that can lead to blindness by lowering eye pressure.
Laser surgery is also covered for the treatment of Benign Prostatic Hyperplasia (BPH), a non-cancerous enlargement of the prostate gland. Procedures like Holmium Laser Enucleation of the Prostate (HoLEP) or Photoselective Vaporization of the Prostate (PVP), often known as Greenlight Laser, are covered as they treat urinary obstruction and restore normal function. Furthermore, certain dermatological laser procedures, such as the destruction of precancerous lesions like actinic keratoses, are covered because they prevent the progression of a skin condition into a more serious cancer.
Understanding Non-Covered Laser Procedures
Medicare explicitly excludes coverage for laser surgeries considered cosmetic or elective, as they fail to meet the medical necessity criteria. The most well-known exclusion is Laser-Assisted In Situ Keratomileusis (LASIK) and other refractive eye surgeries. Since these procedures primarily aim to reduce dependence on glasses or contact lenses, they are classified as elective vision correction.
Laser procedures used solely for aesthetic purposes are also not covered. This includes laser skin resurfacing performed for the removal of fine lines, wrinkles, or age spots purely for cosmetic improvement. Similarly, laser hair removal is not covered unless it is required to treat a documented medical condition, such as chronic ingrown hairs causing recurrent infection.
Patient Costs and Financial Responsibilities
When a laser surgery is covered because it is medically necessary, the beneficiary still has financial responsibilities that vary depending on the Medicare part involved. For most laser surgeries performed in an outpatient setting, coverage falls under Medicare Part B, which generally pays 80% of the Medicare-approved amount. After the annual Part B deductible is met, the patient is responsible for the remaining 20% coinsurance.
If the procedure requires an inpatient hospital stay, the costs would be covered under Medicare Part A (Hospital Insurance). Part A involves a deductible per benefit period, and coinsurance payments may apply for longer hospital stays. The physician’s services, even during an inpatient stay, are still paid for under Part B.
Medicare Advantage Plans (Part C) are private insurance plans contracted with Medicare. They must cover all the same medically necessary laser surgeries as Original Medicare. However, the patient’s out-of-pocket costs, such as copayments, deductibles, and coinsurance, can be structured differently than the standard 20% coinsurance under Part B. These plans may also offer supplemental benefits that could potentially cover services that Original Medicare excludes.