Medicare does not cover plastic surgery when it is for cosmetic reasons only. Coverage may be available when plastic surgery is for reconstructive purposes.
Medicare is the federally funded health insurance program for adults over age 65. Adults under age 65 with certain health conditions may also qualify.
Part A covers costs associated with hospital stays. Part B covers outpatient care, such as diagnostics tests, doctor’s office visits, and some minor surgical procedures.
There are different types of plastic surgery, and Medicare may pay for elective procedures under specific circumstances.
This article looks at when Medicare may approve plastic surgery costs, when they may not, associated expenses, and more.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Generally, plastic surgery falls into two categories.
According to the American Society of Plastic Surgeons, reconstructive plastic surgery restores or corrects the appearance and function of a part of the body.
Disease, injuries, and congenital irregularity can all lead to defects that interfere with function and appearance.
Examples of reconstructive surgeries that are usually covered by Medicare, include:
- cleft lip repair
- breast reconstruction after cancer
- surgery to repair injuries due to burns or trauma
In some cases, plastic surgery is strictly for appearance only and not part of treatment for a medical issue.
According to the American Academy of Cosmetic Surgery, cosmetic surgery enhances appearance through medical and surgical procedures.
Examples of cosmetic plastic surgery include:
- breast augmentation (not due to breast reconstruction)
- tummy tuck
Usually, Medicare does not cover plastic surgery.
Medicare covers plastic surgery when needed to repair damage from an illness, accident, or due to a misshapen body part.
In some cases, cosmetic and reconstructive surgeries may also overlap, but Medicare covers plastic surgery in the following examples.
Repair after an accidental injury
Crushed bones and burns can leave someone with injuries that affect appearance and function.
Medicare cover may include surgery to treat burns or facial reconstruction after an accident.
Breast reconstruction after a mastectomy
A mastectomy involves the removal of one or both breasts, usually as part of cancer treatment.
Breast reconstruction surgery involves different techniques to reshape or rebuild the breast(s) after mastectomy.
Usually, Medicare covers breast reconstruction.
Medically necessary cosmetic procedures
In many cases, the main and only focus of cosmetic surgery involves improving appearance.
For example, a rhinoplasty, also known as a nose job, may straighten a crooked nose or remove a bump.
Medicare will not cover a rhinoplasty when is it performed only for the improvement of appearance.
However, sometimes a person may experience difficulty breathing, and a nose job could be medically necessary to improve function.
Although a cosmetic benefit may occur as a result of the surgery, the main reason for the procedure is to improve the functioning of the nose.
In this case, if a cosmetic procedure is medically necessary, Medicare provides coverage.
Correction of a malformation
Medicare also pays for plastic surgery required to treat a congenital irregularity.
Certain congenital conditions may lead to structural anomalies, which may affect both appearance and function.
For example, a cleft lip is present from birth and treatable with plastic surgery.
Medicare will only pay for medically necessary procedures, but whether coverage comes from Part A or Part B will depend on the setting of the surgery.
Part A covers medically necessary plastic surgery performed as an inpatient. Coverage includes general nursing care, meals, and a semi-private room.
Part B provides coverage for surgery performed in an outpatient setting.
A person’s doctor should be able to advise whether a procedure is an inpatient or outpatient service, which can help when managing out-of-pocket costs.
Exclusions for Medicare’s coverage of plastic surgery include procedures performed entirely to improve the appearance without a medical need.
When Medicare covers plastic surgery, an individual may have some out of pocket expenses, such as deductibles and copayments, but these will vary depending on whether coverage comes from Part A or Part B.
A person admitted to the hospital for medically needed plastic surgery will pay a $1,408 deductible in 2020.
Individuals who stay in the hospital for less than 60 days do not pay additional coinsurance.
Medically necessary plastic surgery performed in an outpatient setting and covered by Part B requires a person to pay a $198 deductible in 2020.
Part B also requires a person to pay a 20% coinsurance toward Medicare-approved costs.
Additional out of pocket expenses may vary based on the procedure and individual needs. For example, a copayment may exist for prescription pain medication needed after surgery.
Medicare does not cover most alternatives to cosmetic plastic surgery.
Alternatives to cosmetic surgical procedures include injections, such as Botox and fillers.
Laser treatments, chemical peels, and microdermabrasion are also non-surgical alternatives to plastic surgery. If these treatments are conducted solely to alter appearance they are not eligible for coverage through Medicare.
Although Medicare does not cover these alternatives, the procedures are less costly, which may make them an option for some people.
Alternatives for reconstructive surgery are available and the options depend on a person’s circumstances. For example, if someone would prefer not to undergo breast reconstruction, wearing a prosthesis may be preferable.
Other insurance coverage options, such as a Medicare Advantage plan, do not provide an alternative way to have cosmetic procedures covered.
Typically, Medicare Advantage plans cover plastic surgery only if original Medicare covers the procedure.
Medicare coverage for plastic surgery depends on the medical need for the procedure.
Plastic surgery can include reconstructive options that restore function and appearance due to an injury, congenital irregularity, or disease.
Medicare covers medically necessary reconstructive surgery, but they do not cover procedures that are cosmetic and only to enhance the appearance.
Out-of-pocket costs vary depending on which part of original Medicare covers the service. A doctor can offer advice on this.
The same rules and exclusions for plastic surgery coverage apply to both original Medicare and Medicare Advantage plans.