Medicare Coverage for Plastic Surgery

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If you are a Medicare beneficiary, you may be asking, Does Medicare cover plastic surgery? However, the answer is complex.

Depending on the circumstance and procedure, Original Medicare may or may not cover plastic surgery. Medicare will not cover elective plastic or cosmetic surgery. Yet, medically necessary plastic surgery may receive coverage.

Below, we review Medicare’s guidelines for plastic surgery benefits. We review what Medicare covers, what is not, and how to find a physician to cover your services. Most importantly, we answer your original question, does Medicare cover plastic surgery?

Plastic surgery and cosmetic surgery are not the same. Plastic surgery repairs body parts that may suffer damage due to disease, trauma, or birth defects. Meanwhile, cosmetic surgery enhances certain features of your face or body.

Because the two types of surgeries are not the same, different doctors often perform them. However, many certified plastic surgeons also perform cosmetic procedures.

Medicare will only cover medically necessary plastic surgery after other treatment options have been unsuccessful. There is no circumstance where Medicare will cover elective cosmetic surgery.

To qualify for Medicare coverage, you must maintain your weight for at least six months, monitored by a physician. Further, you must try other ways to reduce the loose skin for at least three months. You must provide documented progress and have a physician recommend the procedure.

To qualify for a breast reduction surgery, you must have ongoing symptoms for at least six months and try non-surgical treatments with no improvement. However, Medicare will only cover breast prostheses if you have breast cancer.

If you have breast cancer, a lumpectomy or mastectomy can occur immediately or years later, depending on your needs.

This procedure involves removing skin tissue to remove the cancerous cells. However, Medicare will not cover plastic surgery after Mohs surgery in most cases.

Original Medicare will cover the Mohs surgery procedure. However, it will not cover the cost of reconstructive surgery for the removed skin.

Typical covered conditions include:

  • Accidental injury – If you are injured in an accident that produced visible trauma to a part of your body, you may be eligible for Medicare-covered plastic surgery. For example, if you fall and suffer damage to your mouth, Medicare may cover the required plastic surgery to restore your mouth’s prior appearance and functionality.
  • Breast reconstruction after mastectomy – Suppose you are diagnosed with breast cancer and have a mastectomy. In that case, Medicare will typically cover the reconstruction surgery for your breasts as well as external breast prosthesis and post-surgical bras.
  • Malformation – Medicare will cover plastic surgery to repair malformed body parts if deemed medically necessary. However, malformation is the trickiest plastic surgery procedure to be approved. If the surgery is not deemed medically necessary, Medicare will not cover it.
  • Rhinoplasty – Rhinoplasty is a nose job. Medicare will cover the plastic surgery costs if you require a nose job to help alleviate strained breathing, fix a congenital defect or traumatic injury, or treat chronic nasal obstruction. However, the procedure must be medically necessary, and your physician must prove that a less invasive treatment option will not adequately treat the complication.
  • Vein Ablation – Vein ablation can treat veins that cause skin ulcerations, decrease the frequency of superficial thrombophlebitis, and treat pain and swelling that will not go away with medication.
  • Blepharoplasty – If you suffer from painful eye spasms, nerve palsy in your eye, obstructive upper eyelid, or complications from other medical conditions, Medicare may cover blepharoplasty. Additionally, if plastic surgery is necessary in preparation for a prosthetic eye, Medicare will also cover the cost of the surgery.
  • Botox injections – This may come as a surprise as Botox injections are typically considered a cosmetic procedure. However, in many cases, Botox can treat severe migraines and muscle spasms in the neck. If you have tried other medications and nothing is working, Medicare may cover the cost of Botox injections as treatment.

The above list is not all-encompassing when it comes to Medicare-covered plastic surgery. However, it is some of the most popular covered surgeries. In every case, your physician must deem the surgery medically necessary, and the case will have to be reviewed individually by Medicare to decide if the treatment will receive coverage.

Common cosmetic surgeries Original Medicare does not cover are:

  • Facelift
  • Breast Lift
  • Body contouring

Medicare Plastic Surgery Prior Authorization Process

For Medicare to cover plastic surgery, it must pass a prior authorization process. This process requires authorization before the surgery. If the doctor’s office fails to receive prior approval, Medicare will not cover the costs of the procedure.

Your physician’s office must provide Medicare with medical records indicating that plastic surgery is medically necessary. Based on your medical records, a Medicare Administrative Contractor will determine whether Medicare will pay for the procedure.

Each Medicare Administrative Contractor can individually determine the necessity of the requested procedure. So, a procedure may receive coverage under one condition but not under another. This process can take up to two or more weeks.

Once an Administrative Contractor approves a procedure, Medicare will cover the costs. However, if the prior authorization is denied, your physician may provide more documentation until it is approved. Or, you may be responsible for the full cost of the procedure.

If your prior authorization request was denied or your physician did not get proper clearance from Medicare, you may need to sign an Advance Beneficiary Notice. This is a document stating that Medicare may not cover your costs, and you could need to cover the services in full.

If you receive a Medicare-covered plastic surgery that requires an inpatient hospital stay, Medicare Part A and Part B will cover your costs. However, if you are receiving an outpatient plastic surgery procedure, Medicare Part B will provide coverage. Additionally, any medications you require following the surgery will receive coverage by Medicare Part D.

Since most medically necessary plastic surgeries are inpatient, Medicare Part A will cover your first 60 days in the hospital at 100% after you meet the Medicare Part A deductible. Then, after you reach the Medicare Part B deductible, your plan will cover you at 80%. However, you can enroll in a Medicare Supplement plan to help offset these costs.

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