OBJECTIVE: In recent decades, many physicians have chosen to opt out of Medicare, allowing them to set their own pricing models for their patients. Characterization of Medicare opt-outs has yet to be thoroughly studied in neurosurgery. Our study aimed to characterize factors that may influence a neurosurgeon's decision to opt out of Medicare acceptance and contextualize factors both within the field and across various surgical specialties. METHODS: This retrospective cross-sectional analysis used 2010-2024 Centers for Medicare & Medicaid Services data on starting date of physician opting out and geographic state of practice for neurosurgeons and other specialty surgeons. Additional parameters were collected from publicly available profiles of neurosurgeons including medical school graduation year, subspecialty, and type of practice. RESULTS: A total of 63 (1.63%) neurosurgeons opted out of Medicare. The rate of Medicare opt-outs was highest for neurosurgery during 2023, whereas for most other surgical specialties it was highest between the years 2015 and 2017. Of opt-out neurosurgeons, 54.0% were exclusively private practice physicians. Most were spine (66.7%) or general (20.6%) neurosurgeons. Most Medicare nonparticipating neurosurgeons chose to opt out in their mid-career compared with early or late career. A higher number of these neurosurgeons were located in Alaska, Iowa, California, Connecticut, Florida, and New Jersey. CONCLUSIONS: The circumstances influencing a neurosurgeon's decision to opt out of Medicare acceptance are multifaceted. Our findings suggest that physician experience, specialty, location, and practice structure all may play roles and should be investigated further.