Medicare and Plastic Surgery - The Costs it Covers

The plastic surgery industry continues to grow in popularity which means more Americans than ever before are seeking out cosmetic procedures to enhance and rejuvenate their appearance. Some of the potential patients for plastic surgery include those who are on Medicare which means they might be unsure about the procedures covered by their insurance. Let’s look at the rules that are in place for Medicare in order to see what is covered and which costs patients will need to pay for on their own.

Medicare and Plastic Surgery – When will Medicare Cover Some Expenses?

In general, Medicare will cover plastic surgery that is considered to be medically necessary (as opposed to an elective procedure). Medically necessary plastic surgery includes procedures that fall under the heading of “reconstructive plastic surgery”. This is a plastic surgery category that include medical procedures performed to repair damage to areas of the body that are the result of injury or trauma, cancer or some sort of malformation such as a cleft lip or cleft palate.  On the other hand, cosmetic plastic surgery is a procedure that is being performed in order to augment or enhance the appearance of a body part or rejuvenate the look of the facial features of the body.

Let’s take a deeper look and expand on the medical situations or issues where Medicare will normally cover the cost of plastic surgery:

• Damage that is the result of trauma or injury – Patients that suffer an extreme amount of trauma or injury to the body can experience severe damage to various parts of the body including the bones, skin and muscles. A common example of trauma to the body that can result in severe wounds is a person that suffers burns on the body.
• Breast Reconstruction Surgery after a Mastectomy – Patients that have a cancer diagnosis might need to undergo either a full or partial mastectomy to address the cancer that is present in the body. These patients might be eligible to undergo breast reconstruction surgery that is performed by placing breast implants in the body. The surgeon can also move fat, skin or muscle from another part of the body of the actual patient in order to reconstruct the breasts during flap reconstruction.
• Improve the Functionality of Malformed Body Parts – Many people suffer from birth defects, as well as developmental or congenital abnormalities, that can have a negative impact on the formation of body parts. There are times when plastic surgery can be performed to help improve the daily functionality of these malformed body parts.

There are also times when certain procedures can be considered to be both reconstructive and cosmetic in nature. Common examples include rhinoplasty which can give the nose a more aesthetic appeal and improved functionality or blepharoplasty (eyelid surgery) to restore vision that is blocked or impaired by excess skin and fat in the eyelids.

Cosmetic Surgery Not Covered by Medicare

Some of the cosmetic surgery procedures that are not determined to be “medically necessary”, and will not be covered by Medicare, include a breast lift, liposuction or a facelift. If the procedure is considered to be for purely aesthetic reasons, there is a good chance that it will not be covered by Medicare.

Out of Pocket Costs and Medicare

The amount of the costs of a surgical procedure that patients will need to pay for on their own depends on the type of Medicare plan they have for their coverage.

• Medicare Part A covers a hospital stay and any inpatient procedures if a person is admitted to the hospital for trauma or injury that will require plastic surgery to treat the issue.  The patient will still be responsible for their deductible and any applicable coinsurance amounts.
• Medicare Part B will cover medically necessary procedures that are performed in an outpatient setting. The patient is still responsible for the deductible and 20\\% of the Medicare-approved amount for the procedure (once the deductible is met).
• Medicare Part C (also known as Medicare Advantage) covers any plastic surgery procedures that will be covered under original Medicare. The main difference between the two plans are the amount and type of copayments owed (if the doctor performing the procedure is an out-of-network provider).

Medicare and Plastic Surgery – Meeting the “Medically Necessary” Criteria

Patients that want more information about whether or not their plastic surgery choice meets the criteria for being “medically necessary” should consult with the surgeon they want to perform the procedure. The surgeon can answer any questions about the procedure and its results along with questions about the portion of the surgery cost that will be covered by Medicare.

Even though the doctor will likely have the necessary information about which costs (if any) are covered by Medicare, there might be a need to check with another source of information. The healthcare provider can also provide the necessary information regarding any questions about coverage and costs. Finally, the patient can also contact Medicare directly to ask any questions they have about coverage of their “medically necessary” (or not) plastic surgery procedure.

- MA