Medicare will likely cover plastic surgery following an illness or injury, but don’t expect it to pay for purely cosmetic procedures.
Most Medicare coverage decisions come down to two factors: Medical necessity and FDA approval. Is the service or procedure medically necessary to treat a medical condition? And has said treatment been approved by the FDA?
Although plastic surgery is generally thought of as elective treatment to improve one’s appearance, it often serves a true medical purpose, such as the skin grafts a burn victim receives. On this page, we look at which types of plastic surgeries Medicare covers, and which are considered mainly cosmetic in nature.
What’s the difference between plastic surgery and cosmetic surgery?
Before we discuss Medicare coverage of plastic surgery, let’s discuss the terminology so you understand the difference between plastic surgery and cosmetic surgery. The two terms are often used interchangeably; understanding the difference is vital to understanding Medicare’s coverage.
When most Americans hear the word plastic, they think of something synthetic and artificial. However, the “plastic” in plastic surgery derives from the Greek word “plastikos,” which means to form or mold.
According to the American Board of Cosmetic Surgery, cosmetic surgery is only one subcategory of the work done by plastic surgeons. Here are the six training categories for plastic surgeons:
- Hand surgery
- Reconstructive surgery
- Trauma surgery
- Congenital defect repair
- Cosmetic surgery
There are different types of cosmetic surgery:
- Tummy tucks after weight loss
- Breast surgery
- Face surgery
- Other cosmetic surgeries
So, cosmetic surgery is a category of plastic surgery.
Medicare coverage of plastic surgery
Medicare covers medically necessary plastic surgery procedures. Some of those surgeries could be considered cosmetic in some situations. But if you want the surgery for only cosmetic reasons, Medicare will not help pay for it.
Types of plastic surgery Medicare covers
Here are examples of when Medicare will pay for plastic surgery.
Repairing damage after an injury or trauma
Medicare may pay for your plastic surgery if you experience an accidental injury, such as a complex wound or burn, that damages your skin, muscles, or bones.
Repairing a malformed body part to improve function
There are many reasons a body part becomes malformed. Medicare may help pay for the reconstructive procedures if the body part’s function is impaired.
For example, aging and disease can impair the proper functioning of body parts. Congenital abnormalities can also affect the way specific body parts function.
Breast reconstruction surgery following a mastectomy for breast cancer
Medicare covers breast prostheses if you had a partial or total mastectomy because of breast cancer. Breast reconstruction surgery can be performed with artificial breast implants or with your own body tissue.
After a mastectomy, Medicare also covers some external breast prostheses (including a post-surgical bra).
Other medically necessary plastic surgeries Medicare may cover
Some medically necessary plastic surgery procedures may also be classified as cosmetic. Speak with your healthcare provider to determine if Medicare will cover your plastic surgery.
Here are some examples of medically necessary cosmetic procedures.
- Blepharoplasty: Surgery on your eyelid to remove droopy, fatty, or excess tissue to improve the patient's vision.
- Botox injections: Injections used to treat migraines as well as muscle disorders that result in spasms or twitches.
- Panniculectomy: Surgery to remove excess skin and tissue from your lower abdomen if it interferes with your daily activities or results in severe skin conditions. If the surgery is done for cosmetic purposes, it is called an abdominoplasty.
- Rhinoplasty: Surgery to correct a malformed nasal passage and change the shape of your nose. The common term for rhinoplasty is a “nose job.”
- Vein ablation: Surgery to close off veins.
Please note that you must have prior authorization from Medicare to receive coverage for these procedures.
Examples of plastic surgery that Medicare does not cover
If plastic or cosmetic surgery is NOT medically necessary, it is not covered under Medicare.
Here are some examples of surgeries that are not covered:
- Breast lift
- Body contouring
- Breast augmentation (not following a mastectomy)
- Tummy tuck
If you choose to have elective surgery, you will need to pay for all of the expenses for the procedure out of pocket.
Original Medicare and plastic surgery
Again, if the plastic surgery is not medically necessary, you pay 100% of all the costs. However, if the surgery or procedure is medically required, here’s how Medicare coverage works.
Medicare Part A
Medicare Part A (hospital insurance) covers medically necessary surgeries that require a hospital stay.
For example, Medicare Part A will cover surgically implanted breast prostheses after a mastectomy if the surgery occurs in an inpatient setting.
The patient is responsible for paying the deductible, which currently is $1,600 for each inpatient hospital benefit period.
Medicare Part B
Medicare Part B (medical insurance) covers certain doctors’ services, outpatient care, medical supplies, and preventive services. This includes some external breast prostheses after a mastectomy. Part B will also pay for surgically implanted breast prostheses if it takes place in an outpatient setting.
If the procedure is covered under Medicare Part B, the patient will pay the $226 deductible and 20% of the Medicare-approved amount for the services.
Medicare Part C
Medicare Part C (Medicare Advantage plans) are required to cover everything Original Medicare covers. However, these plans may offer additional coverage, such as dental and vision coverage.
It’s important to compare Medicare plans carefully before joining a plan. Luckily, that’s easy to do with our Find a Plan tool. Just enter your zip code to see the costs and benefits of Medicare plans in your area. Or, call us toll-free at 888-992-0738 and a licensed Medicare agent will answer your questions and help you choose the right coverage for your unique needs.