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What Does Medicare Cover?: Plastic Surgery

Do you know what the difference is between plastic surgery and cosmetic surgery? A major difference is that Medicare will cover one, but not the other.

What is plastic surgery?

Plastic surgery, which is different from cosmetic surgery, is the reconstruction or repair of body parts. This can include defects from birth disorders, burns, or trauma.

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Plastic vs cosmetic surgery

Plastic surgery is not the same as cosmetic surgery. However, the two are commonly confused with one another. Plastic surgery is used to reconstruct face and body defects, while cosmetic surgery is only used to enhance a person’s appearance. Plastic and cosmetic surgery are not typically used in emergency situations, so they are considered elective surgeries.

Medicare coverage

Medicare will not cover an elective cosmetic procedure, but there are scenarios in which a cosmetic procedure is deemed medically necessary. That is when Medicare will cover the costs for beneficiaries. These scenarios typically happen after an injury or trauma, or even something that was not previously an issue and is now.

Reconstructive surgery is typically deemed medically necessary when the trauma or defect is caused from a medical condition. For example, reconstructive surgery might occur during treatment for breast cancer. In this case, Medicare will cover 80 percent of the costs. That means that you will be responsible for the remaining 20 percent.

Once the procedure is considered medically necessary, if the procedure is performed in a hospital setting, Medicare Part A will provide coverage. If the procedure is outpatient, Part B will cover the costs.

The major plastic surgery conditions that Medicare will likely deem medically necessary are as follows:

  • After mastectomy due to cancer, reconstruction on one or both breasts
  • Repairs after an accident that caused an injury or trauma
  • Improving function of a body part that will improve quality of life

For more information, talk to your doctor or healthcare provider about what options are available to you.

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