Medicare Coverage of Reconstructive Surgery


What It Is

Reconstructive surgery

What's Covered

Medicare Part A covers inpatient costs, and Medicare Part B covers doctors' charges and outpatient costs, for reconstructive surgery in only three situations:

  • To repair the body following an accidental injury

  • To improve the function -- not just the appearance -- of a body part that never developed or formed properly

  • To reconstruct one or both breasts following a mastectomy

Note: Neither Medicare Part A nor Medicare Part B covers any surgery that's solely for cosmetic purposes (except as described above).

If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for reconstructive surgery, contact the plan directly.

What Medicare Pays:

Hospitalization: If you're admitted to the hospital for covered reconstructive surgery, you pay the Medicare Part A deductible of $1,068 before Medicare pays anything. After that, Medicare Part A pays the full amount of covered inpatient hospitalization charges for up to 60 days. For stays longer than 60 days, see What are Medicare Part A and Medicare Part B premiums, deductibles, and coinsurance amounts in 2009?.

Doctor's care and other outpatient care: For the doctors who perform covered reconstructive surgery, and for all related outpatient care not performed at a hospital outpatient department, Medicare Part B pays 80 percent of the amount approved by Medicare for those services.

Warning: If the covered surgery is performed or related care provided in a hospital outpatient department, a patient may be responsible to the hospital for a co-payment above the Medicare-approved amount.

Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:

  • The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?

  • The care must be performed or delivered by a healthcare provider who participates in Medicare.

Was this medicareinformation helpful?

7 Comments So Far. Add Your Wisdom.

4 months ago

My mother had oral cancer and now needs new bottom dentures because off some bone removal. Would any of that be covered?


11 months ago

82 VET HAD BASILCELL CANCER REMOVED ON 9/30/13 LEFT LARGE HOL IN MY NOSE,WILL NEED PLASTIC SURGERY,I'M ON MEDICARE AND VA WILL MEDICARE PAY OR HELP PAY PLESE ADVISE ME SPUTTY88 2GMAIL.COM DON OBRIEN SR


almost 2 years ago

I have ptosis of my eyes (Horner's syndrome) due to a pancoast tumor of my right lung. Will Medicare cover the eyelid surgery that will allow me to see again? I am rapidly losing sight in both eyes. My secondary carrier has agreed to pay costs of what Medicare will not cover. .


Anonymous said almost 2 years ago

I am on social Security Disability for autoimmune disease, but at the tiem, Severe Morbid obesity was also part of my disability. I have lost a massive amount of weight through bariatric surgery, which has left large curtains of hanging skin on my thighs. It has contributed to repeated cellulitis infections, and has become a hygiene problem as well, no matter how meticulous I am about showering. My PCP has told me that I need to have this skin removed, and Medicaid has already approved the procedure. In a case like this, is Medicare likely to also approve the surgery, wchich will take about a year to complete?


about 3 years ago

Hello tcb, Thank you very much for your question. If you'd like, you can post your question in our Ask & Answer section, here: ( http://www.caring.com/ask ). Take care -- Emily | Community Manager


about 3 years ago

how do you file a medicare claim when the MD "does not participate" in medicare? He wants to be paid. May I fill out a claim form and send to medicare? If so, where might I locate claim form? thank you.


about 4 years ago

I would like more information on partial mastectomy and reconstructive surgery from anybody - those who had had it, need it, or know something about how to get it. Please help....


Default_avatar-hhd399496100

Want More Medicare Info?

< Browse Other Medicare Topics
Stay Connected With Caring.com

Receive the latest news and tips in your inbox

Join our social communities: