Medicare Coverage of Reconstructive Surgery
What It Is
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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