Medicare and Plastic Surgery: What It Does and Does Not Cover (2024)

Medicare does not cover cosmetic plastic surgery. It only pays for medically essential plastic surgery to treat trauma, malformations, or breast reconstruction after mastectomy. You still need to pay out-of-pocket costs such as deductibles and copays.

Plastic surgery is a billion-dollar industry. If you’re a Medicare beneficiary, you may wonder if Medicare covers certain plastic surgery procedures.

While Medicare does not cover elective cosmetic surgery, it does cover medically necessary plastic surgery. This rule is not likely to change anytime soon, even as Medicare legislation changes in the future.

In this article, we explore Medicare’s plastic surgery rules, including what is covered, what is not covered, and what out-of-pocket expenses you can expect for these procedures.

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While Medicare does not cover all plastic surgery procedures, it does cover medically necessary plastic surgery procedures. Medically necessary plastic surgery procedures include those that are needed because of injury, malformation, or reconstructive surgery after breast cancer surgery.

Note that plastic surgery and cosmetic surgery are often used interchangeably. However, there are some fundamental differences between the two types of surgeries.

Reconstructive plastic surgery is used to repair areas of the body that may be affected by trauma, disease, or developmental defects. Cosmetic plastic surgery is a type of plastic surgery that is used to enhance the natural features of the body.

If you are enrolled in Medicare, these are the situations when Medicare will cover your plastic surgery:

Repairing damage after an injury or trauma

Injury or trauma to the body can cause severe damage to the skin, muscles, or bones. Trauma to the extremities and complex wounds, such as burns, are common examples of injuries that require plastic surgery.

Repairing a malformed body part to improve function

Birth defects, aging, and disease can all impair the proper functioning of some body parts. Congenital or developmental abnormalities can also affect how certain body parts are formed.

Diseases are another possible cause of abnormal body structure and lack of function. In some cases, plastic surgery can help improve the function of these affected body parts.

Breast reconstruction surgery after a mastectomy for breast cancer

If you have breast cancer and choose to undergo a partial or full mastectomy, you are eligible for breast reconstruction surgery.

Breast reconstruction surgery can either be performed with artificial implants, called prosthetic reconstruction, or with your own body tissue, called tissue flap reconstruction.

Where cosmetic and reconstructive procedures overlap

Some medically necessary plastic surgery procedures may also qualify as cosmetic surgery procedures. For example, rhinoplasty to correct a malformed nasal passage may also improve the look of the nose.

Excess eye skin removal to fix vision problems may improve the look of the eyelid. However, these reconstructive surgeries are not the same as those performed for purely cosmetic reasons.

How can you determine if your medical situation meets the criteria for “medically necessary” plastic surgery? Federal, national, and local laws all determine whether a service or supply is covered under Medicare.

Speak with your doctor or healthcare professional to find out if your plastic surgery procedure will be covered. You can also contact Medicare directly with any coverage questions.

Cosmetic surgery that’s performed for appearance only, and therefore not considered medically necessary, is not covered under Medicare. Here are some examples of common cosmetic surgeries that Medicare does not cover:

• body contouring
• breast lift
• breast augmentation (not following a mastectomy)
• facelift
• liposuction
• tummy tuck

If you decide to undergo these types of procedures, you will not be covered by your Medicare insurance. Instead, you will owe 100% of the procedure costs out of pocket.

Some outpatient plastic surgery procedures, such as rhinoplasty, may be covered by Medicare. These procedures are done in an outpatient clinic, and you can return home the same day as the surgery.

However, most medically necessary plastic surgery procedures are inpatient procedures. These procedures require overnight hospitalization. Some examples of inpatient plastic surgery procedures that Medicare may cover include:

• cleft lip or palate surgery
• facial augmentation
• prosthetic or tissue flap breast reconstruction
• upper or lower limb surgery

Depending on your coverage, whether you require inpatient or outpatient surgery, here are some of the out-of-pocket costs you may encounter.

Medicare Part A

If you’ve been admitted to a hospital for injury or trauma and require plastic surgery, Medicare Part A covers your hospital stay and any inpatient procedures.

You will owe a deductible for each benefit period. For 2024, that amount is $1,632. If you are admitted for a period of 60 days or less, you will not owe any coinsurance. If you are admitted for 61 days or longer, you will owe a coinsurance amount that depends on your length of stay.

Medicare Part B

If you undergo plastic surgery in an outpatient setting, Medicare Part B covers these medically necessary procedures.

In 2024, you will owe a deductible of $240 if you haven’t already paid it for the year. After you’ve met your deductible, you will be responsible for 20% of the Medicare-approved amount for the procedure.

Medicare Part C

Any plastic surgery procedures covered under Original Medicare will also be covered under Medicare Advantage (Part C).

However, one major difference between Medicare Advantage plans and Original Medicare is the copayment amount. Most Advantage plans charge a copayment per doctor or specialist visit, and these payment amounts tend to be higher if you use out-of-network healthcare facilities and healthcare professionals.

If you require reconstructive plastic surgery, your Original Medicare or Medicare Advantage will cover your procedure.

Plastic surgery procedures that are covered under Medicare plans include repairing damage from injury or trauma, improving the functionality of a malformed body part, and breast reconstruction after breast cancer surgery.

Original Medicare and Medicare Advantage plans have their own plan costs, so talking with your doctor about your potential out-of-pocket costs for these procedures is always an important step.