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.

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6 Comments So Far. Add Your Wisdom.

7 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

For this question:

over 1 year 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. .

For this question:

Anonymous said over 1 year 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?

For this question:

over 2 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

For this question:

over 2 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.

For this question:

almost 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....

For this question:

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