This article was updated on February 23, 2021.
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.
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 surgeries 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 by 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. Examples of inpatient procedures would be:
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- Cleft lip or palate surgery
- Facial augmentation
- Prosthetic or tissue flap breast reconstruction
- Upper or lower limb surgery
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 the function of a body part that will improve quality of life
Outpatient cosmetic procedures
There are certain outpatient cosmetic procedures that may require prior authorization before Medicare covers them, such as:
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- Blepharoplasty – Surgery on your eyelid to remove excess tissue.
- Botulinum toxin injections (or “Botox”) – Injections used to treat muscle spasms or twitches.
- Panniculectomy – Surgery to remove excess skin and tissue from your lower abdomen.
- Rhinoplasty (or “nose job”) – Surgery to change the shape of your nose.
- Vein ablation – Surgery to close off veins.
Cosmetic procedures that aren’t covered
Common cosmetic procedures that Medicare usually will NOT cover are:
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- Body contouring
- Breast lift
- Facelift
- Liposuction
- Tummy tuck
If Medicare approves any of these procedures, you would only need to pay your deductible and coinsurance. Remember, Medicare will only cover surgeries that are deemed medically necessary. If you have a Medicare Advantage plan, it should provide the same coverage, however, costs may differ so check with your plan.
