Does Medicare Cover Plastic Surgery?

Medicare does not cover the elective cosmetic procedures that come to mind when many people think of plastic surgery. America’s most common plastic surgery procedures, including liposuction, breast augmentation, and the tummy tuck, are outside the scope of the Medicare program. However, both Original Medicare and Medicare Advantage offer coverage for medically necessary and reconstructive plastic surgeries. Read on to learn more about how Medicare covers plastic surgery.

Plastic Surgery: Reconstructive vs. Cosmetic

There are two types of plastic surgeries: Reconstructive and Cosmetic. Understanding the difference is essential since it explains why Medicare covers some plastic surgeries and not others.

Reconstructive plastic surgery aims to restore a person’s normal appearance and function after an illness or accidental injury. Some examples of reconstructive surgeries include facial repair after a serious car accident or breast reconstruction after a mastectomy. Typically, reconstructive procedures are considered medically necessary.

Cosmetic plastic surgery aims to improve appearance by reshaping standard, healthy parts of the body. Some examples of cosmetic procedures include face lifts, liposuction, and dermal fillers. Medicare does not cover most cosmetic surgery.

Limitations On How Medicare Covers Cosmetic Surgery

Medicare only covers plastic surgery procedures that are considered medically necessary. For example, it does not cover a facelift when it’s performed solely to make a beneficiary look younger. However, it may cover the procedure when fixing a functional impairment, such as facial paralysis.

When a beneficiary needs a procedure that’s typically considered cosmetic, their surgeon may need to get prior approval from Medicare before the surgery is covered. Some procedures that require prior approval include blepharoplasty (or “eyelid lift”) and rhinoplasty (or “nose job”).

The part of Medicare that covers medically necessary plastic surgeries varies depending on how the procedure is performed. Part A (Hospital Insurance) covers surgeries that take place during a hospital stay. Part B (Medical Insurance) covers same-day surgeries.

Eligibility

Beneficiaries may be eligible for Medicare-covered plastic surgery if the procedure is medically necessary. Medicare considers plastic surgery to be medically necessary when used to correct functional impairment of a body part after an accident or illness or to correct congenital, acquired, or traumatic anomalies that are severely disfiguring even when there is no functional impairment.

While eligibility is often determined on a case-by-case basis, the most common criteria include the following:

Functional Impairment: The surgery must address a functional impairment or medical problem significantly affecting the patient’s health, well-being, or ability to perform daily activities. Functional impairments can include problems with vision, breathing, eating, or mobility.
Failed Conservative Treatments: In some cases, Medicare may require documentation showing that conservative or non-surgical treatments have been tried and failed to alleviate the medical condition or impairment.
Consistency with Medicare Policies: The surgery must align with Medicare’s coverage policies, which can vary by region and may be subject to change. Local Medicare Administrative Contractors (MACs) and their interpretation of Medicare guidelines may also influence coverage decisions.
Preventing Further Complications: Medicare may approve plastic surgery when it is necessary to prevent further complications, worsening of the medical condition, or the development of new medical problems.

Types of Plastic Surgeries Typically Covered By Medicare

Medicare offers coverage for a variety of medically necessary plastic surgeries. Here’s a look at some critical types of procedures available to Medicare beneficiaries.

Trauma or Injury Damage Repair

Medicare covers plastic surgery procedures needed to repair damage from a trauma or accidental injury. These procedures are considered medically necessary because they aim to restore a person’s needs and ability to function. After an injury or trauma, Medicare may cover procedures like nasal surgery to reconstruct the nose or hair transplants to restore the eyebrows.

Functional Repair of Malformed Body Part

Medicare covers reconstructive procedures used to improve the function of an abnormal body part. Beneficiaries may need these procedures if their body parts are affected by birth defects or diseases. For example, Medicare may cover surgery to close a cleft lip that’s been present from birth or surgery to repair a drooping eyelid that’s affecting a person’s vision.

Breast Prostheses, or Breast Reconstruction After Breast Cancer

Each year, about 240,000 women are diagnosed with breast cancer. Some are treated with mastectomy, a surgical procedure that involves removing the entire breast. After the procedure, Medicare covers surgically implanted breast prostheses to help beneficiaries restore their original appearance.

How Does Medicare Advantage Cover Plastic Surgery?

Because each Medicare Advantage plan is unique, each comes with its own rules for accessing care. However, MA plans are also mandated to offer at least the same amount of coverage as Original Medicare.

Further, Medicare Advantage plans usually cover benefits beyond what Original Medicare offers, but the extra benefits do not extend to elective cosmetic surgeries like liposuction or face lifts. Per long-standing Medicare rules, services primarily used for cosmetic reasons are not eligible for supplemental benefits.

Cost of Plastic Surgery With Medicare

The cost of covered plastic surgery varies depending on which part of Medicare covers the procedure. Beneficiaries can expect to pay a deductible and coinsurance.

For Part A-covered surgeries, the $1,600 Part A deductible applies. Beneficiaries are also responsible for the 20% Part B coinsurance for doctor services billed separately from the hospital’s surgery charges.

For Part B-covered surgeries, an annual deductible of $226 applies. After meeting their deductible, beneficiaries pay 20% of the Medicare-approved amount for their doctor’s services, plus copayments for other surgery-related services.

Costs vary in Medicare Advantage since each plan sets its own deductible and <a class="wpil_keyword_link" href="https://assurance.com/health-insurance/copays-deductibles-and-coinsurance rates. However, plans are required to cap member’s in-network out-of-pocket spending at no more than $8,300 in 2023.

Putting It All Together

Medicare does not cover elective cosmetic surgeries, but it does cover a variety of medically necessary procedures to help beneficiaries restore the function of their bodies. Its crucial coverage helps make procedures like breast reconstruction after mastectomy more affordable. If you need or want a specific plastic surgery procedure, contact Medicare or your plan to determine if it’s covered.

Frequently Asked Questions

If you have Original Medicare, follow the appeal directions printed on your Medicare Summary Notice. If you have a Medicare Advantage plan, check the plan’s initial denial notice to learn how to appeal.

In both Original Medicare and Medicare Advantage, the appeals process has five levels. Beneficiaries who disagree with the result of their first appeal are allowed to file another appeal.

Yes, it’s possible to get a non-covered cosmetic procedure done simultaneously as a medically necessary, Medicare-covered procedure. In these cases, Medicare only pays for the covered procedure, and the beneficiary pays out-of-pocket for the other surgeries.

For example, a person who needs a panniculectomy to remove hanging skin and fat from their lower abdomen may simultaneously choose to have liposuction or other elective procedures. Medicare only covers the panniculectomy, but this partial coverage helps make the whole surgery more affordable.

Medicare typically does not cover services that are required as a result of a non-covered procedure. However, there are certain situations when post-surgical complications of non-covered cosmetic procedures are covered.

Medicare covers complications that occur after a person has been officially discharged from a hospital or surgical center, so long as treating the complications is medically necessary. Some examples of post-surgical complications that may be covered include infection and hemorrhage.

Yes, Medicare covers various services a beneficiary might need to recover from a covered plastic surgery. It covers follow-up appointments with the surgeon to monitor the healing process and identify complications. It also covers rehabilitative services that are necessary after some procedures, such as physical therapy.

Post-surgical medications, such as prescription painkillers, are covered by Medicare Part D. Most Medicare Advantage plans include Part D drug coverage and standalone Part D plans for people with Original Medicare.

How Medicare Covers Plastic Surgery: Limitations to Know