A bunion is a bony bump that develops on the joint at the base of the big toe, often causing pain and discomfort. When symptoms become severe, surgical correction (a bunionectomy) may be considered. Medicare coverage for this procedure is not automatic; it is highly conditional and depends entirely on the surgery being deemed medically necessary.
Original Medicare Coverage Requirements
Original Medicare is divided into Part A and Part B. Part A covers inpatient hospital stays. Bunion surgery is most often performed in an outpatient setting, so coverage typically falls under Medicare Part B (Medical Insurance).
Part B covers outpatient services, including doctor’s services, medically necessary supplies, and procedures performed in an ambulatory surgical center or hospital outpatient department. The fundamental prerequisite for Part B coverage is that the service must be considered medically necessary. If the surgery requires an overnight hospital stay, Part A would cover the facility charges.
Establishing Medical Necessity
For Medicare to cover a bunionectomy, a treating physician must document the procedure as necessary for improving function or alleviating severe symptoms. Medical necessity requires specific evidence that the bony deformity is causing significant, persistent pain or limited mobility that interferes with daily activities like walking or standing. This documentation often includes X-rays showing the severity of the joint damage or toe misalignment.
A primary requirement is that all non-surgical, conservative treatments must have been attempted and failed to provide adequate relief. The medical record must show a history of using measures like wider shoes, protective padding, custom orthotic devices, or anti-inflammatory medications without success. Physicians must submit this detailed clinical evidence to Medicare, sometimes requiring prior authorization before the surgery. Medicare will not provide coverage if the surgery is purely for cosmetic purposes.
Patient Out-of-Pocket Costs
When bunion surgery is approved under Original Medicare Part B, the beneficiary still has financial responsibilities. Before Medicare pays, the annual Part B deductible must be met. For 2025, this deductible is $257, and the patient is responsible for this amount before cost-sharing begins.
Once the deductible is met, the patient is responsible for a standard 20% coinsurance of the Medicare-approved amount for the procedure. This 20% applies to the surgeon’s fee, the facility fee for the outpatient center, and associated services like anesthesia. Since the average cost of bunion surgery can range from approximately $3,500 to over $12,000, the patient’s 20% share can result in out-of-pocket costs of several hundred to a few thousand dollars.
Coverage through Medicare Advantage and Medigap Plans
Beneficiaries with a Medicare Advantage Plan (Part C) receive their Part A and Part B benefits through a private insurance company. These plans must cover the same medically necessary services as Original Medicare, including bunion surgery. However, the cost-sharing structure differs from Part B, often involving fixed copayments and a maximum annual out-of-pocket limit.
Medicare Advantage plans may require the use of in-network doctors and facilities, and they often mandate specific referrals or prior authorizations. Separately, Medicare Supplement Insurance (Medigap) works alongside Original Medicare. Medigap plans help cover the deductibles, copayments, and the 20% coinsurance amount left over by Original Medicare. If Original Medicare approves the claim, a Medigap policy can significantly reduce or eliminate the beneficiary’s out-of-pocket costs.