Does Medicare Cover Kidney Stone Surgery?

This article answers a critical question: Does Medicare Cover Kidney Stone Surgery? Exploring this topic is vital for those navigating the medical complexities of kidney stones and how Medicare covers their treatment.

[keytakeaways]

• Mineral deposits form kidney stones in your kidneys.
• If a kidney stone cannot pass, it may require surgical intervention.
• Kidney stone surgery costs between $7,400 (outpatient) to $20,000 (inpatient).
• Medicare covers medically necessary kidney stone removal.

[/keytakeaways]

What Are Kidney Stones?

Kidney stones are hard mineral deposits made from calcium or waste products such as uric acid. These deposits can block urine and scar your ureter tubes as they pass, causing unpleasant symptoms such as:[mfn referencenumber=2]Mayoclinic.org, “Kidney Stones”, Accessed January 17, 2022[/mfn]

• Acute pain in your low back and sides
• Radiating pain around your groin and lower abdomen
• Painful and/or burning urination
• Brown, pink, or red urine
• Cloudy or unusual smelling urine
• Frequent urination
• Unusually small amounts of urine
• Nausea and vomiting
• Fever and chills

Types of Kidney Stones

Kidney stones can vary in composition, with different types forming due to diet, genetics, and underlying medical conditions. The most common types include calcium stones, formed from calcium oxalate or calcium phosphate, accounting for approximately 80% of kidney stones. On the other hand, uric acid stones develop when there is an excess of uric acid in the urine, often associated with conditions like gout or high-purine diets.

Another type, struvite stones, typically form due to urinary tract infections caused by certain bacteria, leading to the production of ammonia and the precipitation of magnesium ammonium phosphate crystals. Finally, cystine stones are rare due to a genetic disorder that causes cystine, an amino acid, to leak into the urine, forming crystals that can accumulate and grow into stones.

Understanding the different types of kidney stones is crucial for accurate diagnosis and appropriate treatment planning. Stone composition, including dietary modifications, medication regimens, and surgical interventions, can influence treatment decisions. By addressing the underlying causes and characteristics of each stone type, healthcare providers can develop tailored strategies to prevent recurrence and improve patient outcomes.

Kidney Stone Diagnostic Procedures

Accurate diagnosis of kidney stones is crucial for effective management and treatment planning. Diagnostic procedures typically begin with a thorough medical history and physical examination to assess symptoms and risk factors.

Imaging tests are commonly used to confirm the presence of kidney stones and evaluate their size, location, and composition. Computed tomography (CT) scans are highly sensitive and widely used for diagnosing kidney stones because they can detect even small stones and provide detailed anatomical information.

Ultrasound imaging is another common test, particularly in pregnant women or individuals sensitive to radiation. Additionally, laboratory tests such as urinalysis can help identify abnormalities in urine, such as elevated levels of calcium, oxalate, or uric acid, which may indicate stone formation.

Risk Factors and Prevention

Several factors contribute to the development of kidney stones. Dietary factors, such as high sodium intake, animal protein, and oxalate-rich foods, can increase the risk of stone formation. Dehydration, which concentrates urine and reduces urinary volume, also plays a significant role.

Some individuals are predisposed to kidney stones from underlying medical conditions like obesity, metabolic syndrome, and certain gastrointestinal disorders. Genetics may also influence susceptibility. Prevention efforts often focus on dietary modifications, adequate hydration, and lifestyle changes to reduce risk factors and minimize stone formation.

Individuals can reduce their risk of developing kidney stones by addressing modifiable risk factors through lifestyle changes. Adopting a diet rich in fruits, vegetables, and whole grains while limiting sodium, animal protein, and oxalate-rich foods can help prevent stone formation.

Likewise, adequate hydration, particularly water, can dilute urine and reduce the concentration of stone-forming substances. Lifestyle modifications such as maintaining a healthy weight, exercising, and avoiding excessive alcohol and caffeine consumption can also contribute to kidney stone prevention.

Options for the Treatment of Kidney Stones

Small kidney stones may pass on their own, supplemented with proper hydration and diet. Large stones may get stuck in your urinary tract and sometimes need to be removed through surgery. Four treatments are available to remove kidney stones:[mfn referencenumber=3]CMS.gov, “Medicare Coverage Issues Manual”, Accessed January 17, 2022[/mfn]

1. Shock wave lithotripsy
2. Ureteroscopy
3. Percutaneous nephrolithotomy
4. Open surgery

Non-Surgical Treatment Options

Non-surgical treatment options are available for smaller kidney stones and offer alternatives to invasive procedures, particularly those in the kidneys or ureters. One approach is using medications to help facilitate the passage of kidney stones or alleviate associated symptoms.

Pain management medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, may be prescribed to manage discomfort. Alpha-blockers, a medication that relaxes the muscles in the ureter, may help facilitate stone expulsion by widening the ureter and easing passage.

Additionally, medications may be prescribed to address underlying conditions contributing to stone formation, such as hyperuricosuria or hypercalciuria. Another non-surgical option is extracorporeal shock wave lithotripsy (ESWL). This minimally invasive procedure uses shock waves, under X-ray visualization, to break kidney stones into smaller fragments, making them easier to pass.

Recovery Process After Kidney Stone Surgery

Recovery following kidney stone surgery varies depending on the type of procedure performed. Individual factors such as overall health and the size and location of the stones also play a factor.

For minimally invasive procedures like ureteroscopy or shock wave lithotripsy (ESWL), recovery is often relatively quick, with many individuals able to resume normal activities within a few days. Recovery for more invasive procedures such as percutaneous nephrolithotomy (PCNL) or open surgery, may take longer, requiring a hospital stay and several weeks of rest and recuperation.

Pain management is a crucial aspect of the recovery process. Healthcare providers generally prescribe medications to alleviate discomfort and promote healing. Patients are typically advised to maintain adequate hydration and follow a specific diet to prevent the recurrence of kidney stones.

How Much Does Kidney Stone Surgery Cost?

The cost of a kidney stone removal depends on whether your surgery requires an outpatient surgery center, which does not require a hospital stay, or an inpatient surgery service, which does require a hospital stay. Kidney stone surgery can cost around $7,400 to $20,000 without coverage, depending on the severity of the surgery and any hospital costs incurred during your recovery.[mfn referencenumber=4]health.costhelper.com, “Kidney Stone Treatment Cost”, Accessed January 17, 2022[/mfn]

Does Medicare Cover My Kidney Stone Removal?

Original Medicare benefits cover all four common procedures based on your doctor’s recommendation. Your doctor visits, lab tests, imaging, and other outpatient procedures are covered by Medicare Part B.

Medicare pays 80 percent of all Medicare-approved Part B services. The Part B deductible applies. If you have kidney stone surgery in an inpatient setting, Medicare Part A covers your costs after you meet your Part A benefit period deductible.[mfn referencenumber=5]Medicare.gov, “Surgery”, Accessed January 17, 2024[/mfn]

Medicare Advantage Plan Coverage

Medicare Advantage Plans (Part C) are private health insurance plans approved by Medicare. All plans must cover the same benefits as Medicare Part A (hospital insurance) and Part B (medical insurance). However, plans are not required to cover Part A and Part B benefits in the same way.

Specifically, each insurance company assigns its own out-of-pocket costs (deductibles, copays, and coinsurance) the Part A and Part B services. Additionally, plans may require prior authorization for certain services, as well as a referral to see specialists.

Most plans use local provider networks. If you go outside of the network for care, you may be required to pay all costs (HMO) or higher costs (PPO).

What If I Need More Help With The Remaining Costs?

Even after Medicare has provided its share for your kidney stone surgery, you may still find the final bill to be difficult to pay. 20 percent of $7,400 is still $1,480 out of your pocket. This is a situation where having a Medicare supplement insurance (Medigap) policy would pay off.

If you purchase a Medigap plan as soon as you are able, it can help you with any unforeseen out-of-pocket medical expenses that Medicare has covered. This includes:[mfn referencenumber=6]Medicare.gov, “How to compare Medigap policies”, Accessed January 17, 2024[/mfn]

• Deductibles
• Coinsurance
• Copayments
• Blood (the first three pints), if your surgery requires a transfusion

Prescription Drug Plans

As previously mentioned, pain management is a crucial aspect of kidney stone treatment. Most patient will need medications to alleviate discomfort and promote healing. These classes of medications are available through Medicare Part D prescription drug plans.

Summary

Navigating kidney stone treatment if you are on Medicare involves understanding the coverage options available and the associated costs. By exploring the various aspects of kidney stone diagnosis, treatment, and recovery, you will be better to make informed decisions. Whether considering surgical interventions or exploring non-surgical alternatives, rest assured that Medicare covers medically necessary treatments.