Does Medicare Cover Prostate Surgery

Does Medicare Cover Prostate Surgery

Your doctor may order prostate surgery to treat a variety of conditions, from urinary problems to cancer.

A prostatectomy, or prostate surgery, is done to remove some or all of the prostate in the event of prostate cancer, urinary problems, or other symptoms.

If you are scheduled for a prostate cancer screening or were recently diagnosed with prostate cancer and are considering surgery, it’s important to understand your Medicare benefits and possible out-of-pocket costs. Medicare provides beneficiaries with coverage for both prostate cancer screening tests and prostate surgery should it be medically necessary. Read on to learn more.

What is prostate surgery?

A prostatectomy, or prostate surgery, is surgery to remove part or all the prostate gland. Situated in the male pelvis below the bladder, it surrounds the urethra (which carries urine from the bladder). Its primary function is to produce the fluid that nourishes and transports sperm (seminal fluid).

The surgery can be performed in several ways depending on what’s being treated, and it may be used alone or in conjunction with radiation, chemotherapy, and/or hormone therapy or other treatments.

Radical prostatectomy, surgery to remove the entire prostate gland and surrounding lymph nodes, is done to treat localized prostate cancer. This can be done by either robot-assisted radical prostatectomy, where the surgeon makes several small incisions in the lower abdomen to remove the prostate using instruments attached to a robot device (which allows for a more precise response to the surgeon’s movements).

Or, it can be done by open radical prostatectomy, where the surgeon makes an incision in the lower abdomen to remove the prostate. This doesn’t remove the entire prostate, but instead a part of the prostate that’s blocking the flow of the urine to ease symptoms.

Why would someone need prostate surgery?

A prostatectomy is used to treat a number of conditions affecting the prostate, though it’s most commonly used as treatment for prostate cancer. It may also be recommended for men with severe urinary symptoms or very enlarged prostate glands (HP).

What is prostate cancer?

Prostate cancer, which is one of the most common types of cancers, is when cells in the prostate gland begin to grow out of control. Almost all prostate cancers are adenocarcinomas, which develop from the gland cells (which make the prostate fluid that is added to semen).

Other more rare types of cancer that can start in the prostate include:

  • Small cell carcinomas
  • Neuroendocrine tumors
  • Transitional cell carcinomas
  • Sarcomas

Most prostate cancers grow slowly and are confined to the prostate gland, where they don’t cause serious harm. When detected early, prostate cancer has the best chance for successful treatment.

Symptoms of prostate cancer

In the early stages, prostate cancer typically doesn’t have any signs or symptoms.

In more advanced stages, you may have symptoms such as trouble urinating, blood in the urine or semen, bone pain, weight loss, erectile dysfunction, or decreased force in the stream of urine.

Talk to your healthcare provider if you are experiencing any symptoms or have questions or concerns.

Prostate cancer risk factors

Unfortunately, the risk of prostate cancer increases as you age, and is most common after age 50.

Other risk factors include race (African Americans typically have greater risk), family history of prostate cancer or genes that increase the risk of breast cancer, and obesity.

Prostate cancer treatment options

The most common treatment for prostate cancer is surgery, though other options include radiation therapy, cryotherapy, chemotherapy, biological therapy, high-intensity focused ultrasound, or hormone therapy.

Your doctor will help you determine which treatment is right for you.

Medicare coverage for prostate surgery

If you receive a prostate cancer diagnosis, your doctor may recommend prostate surgery. Different parts of Original Medicare will cover prostate surgery depending on the setting.

For example, Part A (hospital insurance) will cover inpatient hospital care, including treatments and surgery. If your prostate surgery must be done in a hospital, your room, nursing, drugs, and other hospital services and supplies will be covered by Part A.

Medicare Part B (medical insurance) covers some preventive services (such as a preventive prostate cancer screening), doctor visits, some intravenous chemotherapy drugs, radiation treatments, diagnostic tests and imaging (including a biopsy), durable medical equipment (DME), outpatient surgical procedures (including outpatient prostate surgery), and other outpatient services.

In some cases, Part B may also cover the cost of a second opinion for non-emergency surgery.

Make sure the provider you see and clinic or hospital you visit accept Medicare assignment.

If Part B doesn’t cover a cancer drug, Medicare Part D (prescription drug plans) likely will. Check your plan’s formulary, or list of covered drugs, to learn what is and isn’t covered and what the cost may be.

Prostate surgery is also covered if you have a Medicare Advantage plan (Part C). Part C plans are required to provide at least the same coverage as Medicare Parts A and B, so both inpatient and outpatient procedures and services will be covered if they are considered medically necessary.

However, you may only get coverage if you go to an in-network provider and hospital. And, your plan may cover additional services that are not covered by Original Medicare, so check with your plan to learn more.

Does Medicare cover prostate cancer screenings?

Medicare Part B covers digital rectal exams (DRE) and prostate specific antigen (PSA) blood tests once every 12 months for men over age 50.

After you meet the Part B deductible, you pay 20% of the Medicare-approved amount for an annual digital rectal exam. If you get the test in an outpatient setting, you may also pay a separate hospital co-pay.

You pay $0 for a preventive PSA blood test as long as the doctor accepts assignment.

Part B may also cover a diagnostic prostate cancer screening if it’s considered medically necessary. After meeting the Part B deductible, you’d be responsible for 20% of the Medicare-approved amount. Medicare pays the other 80%.

How to prevent prostate cancer

You can reduce your risk of prostate cancer by:

  • Consuming a healthy diet full of fruits and vegetables
  • Exercising most days of the week
  • Maintaining a healthy weight

You should also talk to your doctor about your risk of getting prostate cancer and get a prostate cancer screening every one or two years (as your doctor recommends).

Additional resources

After retiring from a career as an executive travel counselor in 2006, Donna Frederick embarked on a second career as a licensed insurance agent. During that first year, many clients told Donna how overwhelmed they felt by Medicare, but that her assistance helped them finally understand the Medicare program. That experience inspired Donna to focus her efforts on educating her clients to ensure they fully understand their Medicare options. Today, Donna takes pride in providing outstanding customer service and going the extra mile to make sure each client knows all of their options and has a sound understanding of their Medicare plan, from costs to coverage and all points in between.


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