Does Medicare cover plastic surgery?

There are a near unlimited number of reasons someone may need or want to use the services of a plastic surgeon. Whether it’s correcting a congenital deformity, reconstructing damaged or burnt tissue, or reducing wrinkles, plastic surgeons can be called upon to help. Whether Medicare will help pay for these services is another story, and a confusing one. We are here to help.

Medicare is explicit that it does not cover what it deems to be cosmetic surgery. This applies to both Original Medicare (Parts A and B) and Medicare Advantage plans. Medicare will only help pay for reconstructive surgery, and have outlined three broad categories they cover:

  1. Surgery to repair damages on the body from accidental injury
  2. Surgery to improve or correct congenital defects
  3. Surgery to reconstruct breast tissue following a mastectomy

In reality, Medicare’s coverage of plastic surgery can be even broader. Medicare also frequently covers tissue reconstruction needed because of disease, like skin cancer. And so long as the surgery is considered medically necessary, it may even cover surgery correcting age-related conditions like “upper eyelid bags” (dermatochalasis).

The key is having Medicare recognize the surgery is “medically necessary”. The standards to prove a procedure is medically necessary vary by state, and your doctor must petition your state’s Department of Human Services for coverage. Often, appropriate evidence includes photos of the affected area and clinical documentation of the ailments it causes.

Medicare does not pre-authorize procedures like other health insurance, but can review your claim before payment. Be sure to use a doctor who knows the Medicare guidelines for your procedure to increase the chances of your surgery being covered. It may be wise to delay your surgery until you are certain Medicare will help with the cost.

Selecting the right doctor

Finding the right doctor may be difficult, however. Medicare reimburses plastic surgeons poorly, and many doctors consider Medicare’s regulations for claims burdensome. Because of this, many plastic surgeons opt out of accepting Medicare. The plastic surgeons in your network may be among these. To find doctors in your area who accept Medicare, visit here.

As with most medical procedures, your costs will vary based on your location, and whether you receive services as an inpatient or outpatient.

If you’re admitted to the hospital for a covered surgery, you pay the Medicare Part A deductible of $1,068. After that, Medicare will pay for hospital charges (that are covered) for 60 days.

If your surgery is performed in an outpatient department, or if you need outpatient care after your surgery, Medicare Part B may pay 80 percent of the Medicare approved amount to your doctor.

For those with prescription drug coverage, pain management related to surgery may be covered by Medicare. You can get prescription drug coverage through Medicare Part D or a Medicare Advantage plan. Since prescription drugs you receive in an outpatient setting aren’t usually covered by Medicare Part B, you should contact your plan to find out how much you will need to pay for your medication.

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