Does Medicare Cover Plastic Surgery?
- Plastic surgery includes a range of procedures that enhance or reconstruct a person’s appearance. Learn Medicare coverage rules for several common surgeries.
Plastic surgery is a broad term that encompasses a wide range of procedures used to improve or reconstruct a person’s appearance. In addition to cosmetic benefits, this type of surgery, which may be used on almost any part of the face or body, often enhances the functionality of the affected area. Because these procedures are sometimes performed to fulfill a medical need, many seniors wonder if Medicare covers plastic surgery. In some cases, the answer is yes, but it depends on what the procedure is and the reason it’s being performed.
Does Medicare Cover Plastic Surgery?
Medicare generally covers the cost of reconstructive plastic surgery, which includes procedures used to repair or reconstruct an area of the face or body damaged through surgery, burns, disease or an accidental injury. Coverage also extends to procedures intended to improve function in a malformed body part, such as a cleft lip. Medicare typically doesn’t cover elective procedures, also known as cosmetic or aesthetic surgeries, which are performed purely to alter a person’s appearance.
Some plastic surgery procedures require prior authorization before Medicare provides coverage. Your physician generally submits the request for authorization along with any supporting documentation. If the procedure is approved, Medicare typically pays 80% of the cost after the deductible has been met. Beneficiaries are still responsible for any coinsurance and copays. If coverage is denied, beneficiaries are responsible for paying 100% of the costs.
Does Medicare Advantage Cover Plastic Surgery?
Although Medicare Advantage coverage terms may differ depending on the individual carrier, policy, and the state of residence, all plans must offer at least the same coverage as Original Medicare. Some policies offer additional coverage for certain procedures, including medically necessary plastic surgery.
Cosmetic Versus Plastic Surgery
The terms cosmetic surgery and plastic surgery are often used interchangeably. However, although these specialties are closely related, they aren’t identical and have different coverage terms under Medicare.
Cosmetic surgery, which may also be referred to as aesthetic surgery, focuses on altering an individual’s appearance to create symmetry, proportion and visual appeal. It’s usually considered an elective procedure and may encompass the following surgeries.
- Breast enhancements: This may include breast reduction, augmentation and lifts.
- Facial contouring: Chin and cheek contouring and nose jobs fall into this category of cosmetic surgery.
- Facial rejuvenation: Surgical facial rejuvenation techniques include lifts to the eyelid, neck and brow.
- Body contouring: Contouring may be done through liposuction or tummy tucks. For men, body contouring options may include male breast reduction.
- Skin rejuvenation: Although they don't involve traditional surgical techniques, laser resurfacing, fillers and Botox are often categorized as cosmetic surgery.
Cosmetic surgeries aren’t covered under Medicare unless they’re deemed medically necessary because of accompanying functional benefits. Medically necessary breast reductions, nose jobs and excess skin removal are several of the cosmetic surgeries that may be covered under Medicare.
Plastic surgery is sometimes referred to as reconstructive surgery because it’s used to repair facial and body defects caused by burns, injuries, disease and birth defects. Although it often has cosmetic benefits similar to aesthetic surgery, plastic surgery’s main goal is usually to improve function.
Plastic surgery may include the following procedures:
- Scar revision surgery
- Reconstruction of the extremities
- Breast reconstruction following cancer surgery
- Birth defect repair (e.g., cleft palate, cleft lip and deviated septum)
Because reconstructive surgeries are often considered medically necessary, they're often covered under Original Medicare and Medicare Advantage.
When Does Medicare Cover Plastic Surgery?
Medicare covers plastic surgery when it’s deemed medically necessary to reconstruct the face or body or to improve the function of a damaged or disfigured body part. Coverage is often approved in the following situations:
- Face or body reconstruction after an accident, injury, infection or disease
- Correction of congenital or developmental abnormalities such as cleft palates or lips, and deformed ears
- Reconstruction as part of treatment for severe burns
- Medically necessary breast reduction
- Medically necessary skin removal surgery after extreme weight loss
- Post-mastectomy breast reconstruction
- Removal of skin tags and warts that are causing bleeding, swelling or may otherwise be harmful
Does Medicare Cover Plastic Surgery for Cosmetic Purposes?
No, Medicare only covers medically necessary procedures, so elective plastic surgery designed to enhance a beneficiary’s looks is not covered under either Original Medicare or Medicare Advantage.
Does Medicare Cover Breast Reconstruction After Lumpectomy?
Medicare covers breast reconstruction surgery or breast prostheses if they're considered medically necessary as a result of surgery to treat breast cancer, including lumpectomies and full or partial mastectomies. Breast reconstruction, which is typically done on an inpatient basis, is covered under Part A once the deductible has been met. Medicare Part B covers associated outpatient costs, including physician visits and pre-surgical testing. Beneficiaries are responsible for any copays or coinsurance.
Does Medicare Cover Skin Tag Removal?
In certain situations, Medicare covers the removal of skin tags, warts and other superficial growths. Typically, coverage for removal is approved if a growth bleeds, exhibits swelling or causes pain or if a doctor believes it might be otherwise harmful to an individual's health. Removal of skin tags for purely cosmetic reasons isn’t covered under Medicare.
Because the procedure for skin tag removal is usually done on an outpatient basis, coverage is provided under Part B. Some plans require a referral.
Does Medicare Cover Rhinoplasty?
Medicare covers rhinoplasty if it’s considered medically necessary, such as when an individual is experiencing breathing difficulties that may be alleviated by reshaping the nose. Medicare doesn’t cover rhinoplasty that’s done strictly for cosmetic enhancement.
Does Medicare Cover a Face-Lift?
No. Because face-lifts are usually performed to create a more youthful appearance and have few, if any, functional benefits, they’re not generally covered under Medicare.
Does Medicare Cover Septoplasty?
A septoplasty corrects a deviated septum by repairing the bone and cartilage that divides the space between nostrils. Because correcting this problem may make it easier for an individual to breathe, promote freer nasal drainage and reduce the risk of sinus infections, the procedure may be covered under Medicare if a doctor orders it for reasons of medical necessity.
Does Medicaid Cover Plastic Surgery?
Because Medicaid is administered by individual states, each area may maintain different coverage terms. Some states may offer dual Medicare/Medicaid coverage to low-income seniors, which can help defray the cost of covered procedures. Contact your local Medicaid office to learn more about what's covered in your state and how to apply for benefits.