Does Medicare Cover Plastic Surgery?

Medicare is a federal health insurance program designed to provide coverage for individuals aged 65 or older, certain younger people with disabilities, and those with End-Stage Renal Disease. When considering plastic surgery, understanding Medicare’s role is important, as coverage extends only to services deemed medically necessary. This means procedures performed to restore function or correct a health condition are considered, while those solely for aesthetic improvement are not.

Criteria for Medicare Coverage

Medicare’s determination for plastic surgery coverage centers on “medical necessity.” A procedure is medically necessary if it is required to diagnose or treat an illness or injury, or to improve the functioning of a malformed body part.

Reconstructive plastic surgery aims to correct or improve a body part abnormal due to a congenital defect, developmental issue, trauma, infection, tumors, or disease. Its primary objective must be the restoration or improvement of physical function, rather than just enhancing appearance.

A physician must officially deem the procedure medically necessary for it to be considered for coverage. This involves a professional assessment that the surgery is essential for health or to restore function. Medicare’s guidelines emphasize that even if a procedure has a cosmetic benefit, its core purpose must be functional restoration.

Procedures That May Be Covered

Several types of plastic surgery procedures may receive Medicare coverage, provided they meet medical necessity criteria. Reconstructive surgery following a mastectomy, often due to breast cancer, is typically covered. This includes breast reconstruction, which can involve implants or tissue flaps, and surgery on the unaffected breast to achieve symmetry. Medicare also covers external breast prostheses and post-surgical bras.

Eyelid surgery (blepharoplasty) may be covered if drooping eyelids severely impair vision or cause other functional problems. Nose surgery (rhinoplasty) can be covered if it corrects a breathing issue, a structural deformity from an injury, or a congenital defect. Medicare does not cover these procedures if their sole purpose is aesthetic enhancement.

Other examples include skin grafts for severe burns or after skin cancer removal, and surgeries to correct significant deformities from accidents or trauma. A panniculectomy, removing excessive abdominal skin that causes medical issues like rashes or infections, may be covered. Breast reduction surgery may also be covered if it alleviates physical symptoms like back pain or neck strain.

Procedures Not Covered

Medicare generally does not cover plastic surgery procedures performed solely to improve appearance. These are considered cosmetic and are not medically necessary for health or functional restoration. Individuals seeking these procedures are responsible for the full cost.

Common examples include facelifts, which aim to reduce visible signs of aging. Tummy tucks (abdominoplasty) performed for cosmetic reasons to flatten the abdomen are excluded. Liposuction, when used for body contouring or weight reduction for aesthetic purposes, does not qualify for Medicare coverage.

Breast augmentation performed purely for cosmetic enhancement is not covered. Hair transplants and Botox injections applied for aesthetic purposes are excluded. If rhinoplasty is sought only for aesthetic improvement, rather than to correct a breathing problem or a deformity, it will not be covered.

Steps to Confirm Coverage

Before undergoing any plastic surgery, confirm coverage with Medicare. Begin by having a detailed discussion with your treating physician regarding the medical necessity of the procedure. The physician’s documentation will explain why the surgery is essential for your health or to restore function.

Understand your specific Medicare plan, whether Original Medicare (Parts A and B) or a Medicare Advantage Plan (Part C). While Medicare Advantage plans must cover everything Original Medicare covers, they may have different rules regarding networks, referrals, and prior authorization requirements. Contact your plan directly to clarify these specifics.

Many non-emergency procedures, including certain plastic surgeries, require prior authorization from Medicare. Your healthcare provider must submit a request and supporting documentation for approval before the procedure is performed. Procedures like blepharoplasty, certain Botox injections, panniculectomy, and rhinoplasty often fall under this requirement.

Always request a written decision or an estimate from your Medicare plan or the provider regarding coverage and potential out-of-pocket costs. Even if a procedure is covered, you will be responsible for deductibles, copayments, and coinsurance. For instance, with Original Medicare Part B, you typically pay 20% of the Medicare-approved amount after meeting the annual deductible, which is $257 in 2025.