Medicare Coverage of Plastic Surgery
What It Is
Medicare Part A or a Medicare Part C plan covers inpatient costs, and Medicare Part B or a Medicare Part C plan covers doctors' charges and outpatient costs for plastic surgery that's considered reconstructive, in three situations:
To repair the body following an accidental injury
To improve the function of a body part that never developed or formed properly
To reconstruct one or both breasts following mastectomy
Neither Medicare Part A, Medicare Part B, nor a Medicare Part C plan covers plastic surgery that's solely for cosmetic purposes.
If you have a Medicare Part C Medicare Advantage plan: Co-payments and deductibles for Medicare Part C Medicare Advantage plans may be different from those for Medicare Part A or Part B. To find out whether your plan has different deductibles or co-payments for covered 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 according to its normal schedule of inpatient coverage and patient copayments. See What are Medicare Part A and Medicare Part B premiums, deductibles, and coinsurance amounts in 2009? Doctor 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, the patient may be responsible to the hospital for a co-payment above the Medicare-approved amount under Medicare Part B.
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.