When will Medicare cover plastic surgery?
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.
Due to the distinctions between these two types of surgeries, there are differences in the education, training, and certification of plastic and cosmetic surgeons:
- Plastic surgeons are certified by the American Board of Plastic Surgery. After medical school, they must undergo at least six years of surgical training and three years of residency training. They must pass a series of exams and take part in continuing education programs each year. Board-certified plastic surgeons only perform surgery in accredited or licensed facilities.
- Cosmetic surgeons must have at least four years of residency experience to become certified by the American Board of Medical Specialties. After this, they can choose to become certified by the American Board of Cosmetic Surgery. However, this is not a requirement.
Many board-certified plastic surgeons also practice cosmetic surgery. To practice both, plastics surgeons must have additional training in cosmetic surgery.
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 as a result of injury, malformation, or breast cancer.
What types of procedures qualify for coverage?
If you are enrolled in Medicare, there are three primary 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 proper functioning of some body parts. Congenital or developmental abnormalities can also affect the way certain body parts are formed. Diseases are yet another possible cause of abnormal body structure and lack of function. In some cases, plastic surgery can be used to 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
There are some medically necessary plastic surgery procedures that may also classify as cosmetic surgery procedures. For example, rhinoplasty to correct a malformed nasal passage may also improve the look of the nose. Or 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 â€œmedically necessaryâ€ plastic surgery? Federal, national, and local laws all determine whether a service or supply is covered under Medicare. Speak with your doctor or healthcare provider to find out if your plastic surgery procedure will be covered. You can also contact Medicare directly with any coverage questions.
What isnâ€™t covered?
Cosmetic surgery thatâ€™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 doesnâ€™t cover:
- body contouring
- breast lift
- breast augmentation (not following a mastectomy)
- face lift
- 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 percent of the procedure costs out of pocket.
What are the out-of-pocket costs for procedures that are covered?
There are some outpatient plastic surgery procedures that are covered by Medicare, such as rhinoplasty. These outpatient 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
Whether you require inpatient or outpatient surgery, here are some of the out- of-pocket costs you may encounter, depending on your coverage.
Medicare Part A
If youâ€™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 of $1,408 for each benefit period. 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 2020 you will owe a deductible of $198, if you havenâ€™t already paid it for the year. After youâ€™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 are the copayments. 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 providers.
If you require reconstructive plastic surgery, you will be covered under your original Medicare or Medicare Advantage plan. 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 always make sure to ask your doctor about your potential out-of-pocket costs for these procedures.
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