Medicare Coverage for Cosmetic Surgery: What You Need to Know

As interest in cosmetic surgery continues to rise, many Americans may want to know if their desired cosmetic surgery is a benefit of their health insurance plan. For people insured by Medicare, this may be of particular interest. This article provides an overview of Medicare coverage for cosmetic and reconstructive surgeries and highlights particular procedures that Medicare may cover if certain criteria are met.

In recent years, there has been a notable increase in the number of Americans expressing interest in cosmetic surgery. The COVID-19 pandemic has been associated as a contributor to this increased demand. During the pandemic, many individuals spent increased time alone and experienced a heightened awareness of their physical features and the appearance of their bodies. Those individuals want to enhance those features as we enter a post-pandemic era.

Additionally, many people hope to obtain a rejuvenated and youthful appearance in response to some of the challenges and distress they experienced during the pandemic. This surge in interest has also led many consumers to inquire if their insurance will cover the costs of their cosmetic procedure.

What is the difference between cosmetic and reconstructive surgery?

It's important to understand that cosmetic surgery, a type of plastic surgery, is generally not considered a medical expense covered by most insurance companies, including Medicare.

Cosmetic surgery is typically an elective surgery or procedure aimed at enhancing or improving the physical appearance of certain personal features. Examples of these procedures include facelifts and tummy tucks. These surgeries aim to improve the person’s overall appearance only and not to resolve or treat a health condition or other physical abnormality.

In contrast, reconstructive surgery, another type of plastic surgery, can sometimes be considered a medically necessary procedure.

Reconstructive surgery aims to improve or restore function to certain body parts with decreased functionality or limitations. A person may have reduced functionality due to certain birth defects, the development of tumors resulting from cancer, or other structural malformations. After reconstructive surgery, a person's health status and quality of life are expected to improve

Medicare will cover the cost of reconstructive surgery if your healthcare provider deems the procedure essential for treating a specific health condition, illness, or injury, demonstrating a legitimate medical need.

What types of surgeries does Medicare cover?

Let’s explore a few specific surgeries covered by Medicare. For all covered surgeries, certain conditions and criteria must be met. Below, we highlight a few surgeries and the conditions under which they are eligible for Medicare coverage.

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Blepharoplasty

Medicare will cover blepharoplasty, also known as eyelid surgery if the procedure is required to improve the visual impairments an individual may be experiencing. An example would be if your vision is impaired due to excess skin from your eyelid covering your pupil. This deformity could be considered a medical issue that needs correcting with reconstructive surgery.

Breast reduction

Breast reduction surgery is generally considered reconstructive surgery. Medicare will consider breast reduction surgery medically necessary in the following scenarios:

• A person who has breasts that are enlarged, and the enlargement negatively impacts other parts of the body. The breasts also have not decreased in size after trialing all non-surgical options.
• A patient who has undergone a mastectomy and a breast reduction is required to improve to improve the symmetry of the breasts.

Lapiplasty

Bunions are a painful deformity of the foot and impact more than 36% of people over 65. Initial treatment and management are non-surgical and can include changing shoe types worn, stretching shoes, utilizing toe spacers, and utilizing non-steroidal anti-inflammatory medications to relieve pain. However, even with non-surgical methods, many patients still need surgical management to relieve pain. A more recent procedure that has become increasingly popular is lapiplasty.

This surgical procedure, considered minimally invasive, can correct deformities caused by bunions and involves less time to recover when compared to traditional bunion surgery. Surgeons can make smaller incisions and utilize specialized instruments to realign the bones in the foot. Medicare covers this procedure as bunion correction is medically necessary since bunions can decrease the functionality of the feet and increase the risks of falls in older patients.

What about Medicare coverage for Liposuction?

According to the Inaugural ASPS Insights and Trends Report, Cosmetic Surgery 2022 by the American Society of Plastic, liposuction has been the number one plastic surgery procedure performed across the United States over the past few years. Many people elect to have this procedure to target unwanted fat in various areas of the body, most commonly in the abdomen and thigh area. This cosmetic procedure removes excess fat from those specified areas to change, enhance, or improve the individual’s physical appearance.

Generally, this procedure is not considered medically necessary or covered by Medicare as it does not treat or improve an underlying health condition or functional abnormality when simply modifying appearance. However, some people may have an underlying condition requiring excess fat removal from a specific area of the body. Your provider should evaluate those conditions, and the appropriate procedures should be followed to justify the procedure's medical necessity to Medicare.

Other covered procedures and medical consultation

In addition to the procedures mentioned above, Medicare also covers other procedures such as:

• Chemical Peels. Medicare will cover chemical peels when used to treat actinic keratosis to improve skin texture.

• Rhinoplasty. Rhinoplasty is a surgical procedure that will change or modify the look and shape of the nose. Medicare will cover this procedure to improve certain types of nasal obstructions impeding functionality.
• Mastectomy due to Gynecomastia. Gynecomastia is a condition that causes males to experience an enlargement of the breasts. Medicare will cover the cost of removing the enlargements if the condition negatively impacts the surroundings, such as the shoulders and neck.

To determine if you qualify for reconstructive surgery, you should consult with your healthcare provider. As Medicare only covers surgeries that are medically necessary, a thorough evaluation of your health condition, disease, illness, injury, or functional abnormality must be evaluated.

For some procedures, Medicare must approve the procedure as medically necessary before your provider can perform it. A review of your medical records and prior treatments may be required to determine your eligibility for coverage. After your consultation visit, your provider will submit the required documentation to Medicare for review and approval.

There has been a surge in interest in cosmetic surgery among Americans over the past few years. As such, evaluating which cosmetic procedures are covered by insurers and which are not is essential. Particularly for those with Medicare, it is important to know if the procedure is reconstructive and required to improve or restore functionality. Reconstructive procedures are more likely to be covered by Medicare. If the procedure is cosmetic and primarily requested to enhance the appearance of certain physical features, Medicare will not cover these expenses.

Procedures not covered by insurers will require individuals to pay the entire cost out-of-pocket. Consulting with your healthcare provider will help make this determination. Understanding some of the specifications of Medicare coverage for various surgical procedures will greatly benefit persons who may need reconstructive surgery. Whether seeking treatment for eye abnormalities or bunion correction, you should be aware of the various components involved with the Medicare decision-making process and what is required to be considered for Medicare coverage.