Tonsillectomies are a very common surgery with more than 530,000 performed each year on children and adolescents in the United States alone. Children aren’t the only ones who may require a tonsillectomy. While less common, some adults may require the removal of their tonsils at some point. If you are in need of a tonsillectomy, it can cost a few thousand dollars, around $3,500. But what if you have Medicare? Are tonsillectomies covered by your Medicare plan, considering it’s rarer for an adult to need a tonsillectomy?
The answer to this big question comes down to a single, all-important phrase — medically necessary. As with many surgeries, if a tonsillectomy is not considered medically necessary, it’s very unlikely your Medicare plan will cover it. In these instances, you could have to pay the full cost out of pocket.
If your procedure is considered medically necessary, it will likely be covered by Medicare. How it’s covered will depend on a few factors, like where you’re receiving the surgery and if you’ve met any deductibles this year.
If you’re receiving the tonsillectomy at an inpatient facility, it’ll be covered under Medicare Part A. Surgeries covered under Medicare Part A will be paid for once you meet the Part A deductible ($1,600 in 2023). There is a copay per day after your 60th inpatient day ($400 in 2023), though a recovery typically doesn’t take that long for a tonsillectomy.
For outpatient procedures, which are very common these days, it’ll be covered under Medicare Part B. With outpatient surgeries, you’ll need to meet your Part B deductible ($226 in 2023) before having 80 percent of your procedure covered. You’d owe the remaining 20 percent.
“Medically necessary” is a bit of a loose term that can refer to many different procedures and services. That’s why it can be tough to determine if a tonsillectomy is medically necessary without looking at your specific case. As we define in our article on what medically necessary means, it must be needed to diagnose or treat an illness, condition, disease, or one of its symptoms. Generally, it must be ordered by a health care provider, like a doctor, and follow the basic standards of medicine.
There are a number of reasons why a tonsillectomy may be medically necessary. Chronic tonsilitis is a common reason, but your doctor may also decide that chronic throat infection, beyond tonsilitis, may necessitate the procedure. If you have frequent bad breath that is caused by pus or debris in the tonsils or obstructive sleep apnea, you may also qualify for a medically necessary tonsillectomy. Whether or not a tonsillectomy is medically necessary for you will come down to your health care provider and if the need fits the criteria.
Without your tonsillectomy being declared medically necessary, you’ll need to cover the entire surgery out of pocket. This can often be the case since many insurance plans consider an adult tonsillectomy an elective surgery, removing the option of a private supplemental insurance plan as a coverage option. If you know that you may need a tonsillectomy in the future, you can talk to your doctor, figuring out what costs you may expect. After that, you can start saving in preparation for the out-of-pocket costs.
Within Medicare, some Medicare Advantage plans may offer additional coverage, though the exact additional coverage differs from plan to plan. You may also try to enroll in a Medicare Medical Savings Account (MSA) plan, a high-deductible plan that is paired with a special savings account you can use for medical expenses (like tonsillectomies). You could also enroll in a Medicare Supplement, which may cover some of the costs surrounding the procedure, even if it doesn’t cover the tonsillectomy itself.
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While tonsillectomies are very common procedures, they aren’t always covered by insurance, whether that’s private plans or through Medicare. Knowing your options and what constitutes a medically necessary procedure, and what doesn’t, makes all the difference. While you may think your need is medically necessary, unless it fits into Medicare’s definition and has a doctor’s order, it’s likely you’ll be paying out of pocket.