Medicare pays for appendix surgery when medically necessary. The surgery may vary depending on the situation.
This article discusses the coverage Medicare provides and possible out-of-pocket expenses related to the appendix surgery.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
The appendix, located on the right side of the abdomen, is a small finger-shaped pouch. Appendicitis is when the appendix becomes swollen and inflamed, which may lead to a severe infection.
While the cause of appendicitis is not clear, the symptoms may include:
- pain in the center or lower right area of the abdomen, worsening over a few hours
- low-grade fever
A burst appendix may spill bacteria into the abdominal cavity, which may cause peritonitis, an infection that can become life-threatening. In some cases, antibiotics may be prescribed to treat the infection, but the primary treatment is surgery to remove the appendix.
Appendix surgery is also called an appendectomy and involves surgical removal of the appendix. The two surgical options include:
A closed appendectomy, which is a minimally invasive surgery (MIS), is done via laparoscopic surgery, in which the surgeon makes a small cut in a person’s abdomen and then inserts a hollow tube, known as a cannula.
Next, the surgeon inserts a laparoscope into the abdomen through the hollow tube. The laparoscope includes a tiny video camera and light.
Using the laparoscope’s camera and light, the surgeon can see inside a person’s abdomen, which is shown on a monitor.
The surgeon then removes the person’s appendix through small abdominal incisions.
A surgeon may choose to perform open surgery if the appendix has ruptured and there is a risk of infection. The procedure may also be done if a person has an abscess, is pregnant and in the third trimester, has a tumor, or has had previous abdominal surgeries.
The operation involves a larger cut in the abdomen so the area can be cleaned. Typically, antibiotics are prescribed after open surgery.
Medicare is a federal health insurance program for older people and some people with disabilities.
- Part A covers inpatient hospital care, including acute care facilities and skilled nursing homes.
- Part B covers outpatient services, such as doctor’s office visits, some cancer screenings, and some medications administered as an inpatient.
- Part C, also known as Medicare Advantage, is optional coverage that replaces original Medicare (Part A and Part B). Private insurance companies offer the plans and must provide at least the same level of benefits as parts A and B.
- Part D is optional prescription drug plan coverage.
Medicare coverage depends on the type of surgery performed, any complications, and the need for additional services.
Part A covers inpatient appendix surgery and the costs associated with the hospital stay. Coverage may include the following:
- nursing care while an inpatient
- semi-private room
- medication administered while inpatient
- medical equipment used during the inpatient stay
Part B may also cover certain aspects of appendix surgery if it takes place as an outpatient or in an ambulatory surgical center. In some cases, an ambulatory surgery center is the setting for an appendectomy when performed laparoscopically, and a person would not stay in the center overnight.
Part B coverage may include:
- doctor’s office visits for follow up care
- anesthesia for surgery performed at an ambulatory surgical center
- facility services fees for an ambulatory surgical center
Part C, Medicare Advantage, also covers appendix surgery. If a person has a Medicare Advantage plan, they will get the same coverage as with original Medicare.
Medicare Part D may pay for services related to appendix surgery. For example, if a person needs prescription pain medication or an antibiotic as part of their treatment for surgery, their part D plan usually covers the drugs.
Medigap plans are optional supplemental insurance. The plans pay out-of-pocket expenses that original Medicare may not pay, including deductibles, copays, and coinsurance.
The costs associated with appendix surgery vary depending on several factors, including:
- the number of days a person is in the hospital
- whether the surgery was done in an ambulatory surgical center or in an inpatient setting
- any complications leading to additional care
In general, people with original Medicare pay a deductible of $1,484 in 2021, which is for each benefit period before Medicare covers the cost. Medicare covers the first 60 days of an inpatient hospital stay after a person meets the deductible.
Appendix surgery does not typically require a long hospital stay unless there are complications. If a hospital stay goes beyond 60 days, a person will pay $371 coinsurance per day for days 61–90.
Medicare recipients also must pay a Part B deductible before Medicare covers the costs. In 2021, the deductible is $203. After meeting the deductible, a person would generally pay 20% of the costs for services.
Medicare may provide coverage for appendix surgery through original Medicare, Part C, and Part D.
Total costs and coverage depend on the surgery, possible complications, and the need for additional services. Out-of-pocket expenses may include deductibles, copays, and coinsurance.