Does Medicare Cover Cosmetic Surgery?
Medicare covers some medically necessary cosmetic surgeries. Medicare will also cover some weight loss surgeries if you meet specific criteria. However, Medicare will never cover a procedure if its only purpose is to improve your appearance.
Which Cosmetic Surgeries Are Covered by Medicare?
Medicare will not cover cosmetic or plastic surgery unless it is considered medically necessary.
- It’s a result of accidental injury.
- It improves the function of a malformed body part.
- You undergo a mastectomy due to breast cancer and you receive breast prostheses for reconstruction.
While surgeries must be considered medically necessary, many procedures that treat health conditions can also improve a patient’s appearance at the same time.
For example, rhinoplasty to correct a malformed nasal passage and chronic breathing issues may also improve how the nose looks. Or removing excessive eye skin to improve vision may also improve the look of the eyelid.
How Much Does Medicare Cover for Cosmetic Surgery?
Costs for medically necessary cosmetic procedures can vary under Medicare.
It’s important to know if your surgery is an inpatient or outpatient procedure.
Inpatient surgeries are covered under Medicare Part A. You will need to meet the standard Part A deductible of $1,408. After that, Medicare pays all covered hospital charges for up to 60 days.
Outpatient procedures are covered under Medicare Part B. You will need to meet the Part B deductible of $198.
After that, you will usually pay 20 percent of the Medicare-approved amount for doctor services. You may also pay the hospital a copayment for each service you get in an outpatient setting.
For both inpatient and outpatient procedures, the surgery must be performed by a health care provider who accepts Medicare.
It must also be ordered or prescribed by a licensed physician or health care provider.
Does Medicare Cover Weight Loss Surgery?
If you are morbidly obese, Medicare will cover some costs of weight loss surgeries.
These procedures are known as bariatric surgery, and they involve altering your digestive system to help you lose weight.
Bariatric surgical procedures include gastric bypass and laparoscopic banding surgery.
It can be difficult to estimate how much bariatric surgery may cost you. It’s important to find out if you’re an inpatient or outpatient.
You’ll need to pay your deductible before Medicare pays anything. You may also owe copayments for the care you receive.
- A body mass index of 35 or greater.
- At least one comorbid condition directly related to your obesity, such as sleep apnea or diabetes.
- Participated in a medically supervised weight loss program.
To be covered by Medicare, weight loss surgery must be performed at a facility that is certified by either the American College of Surgeons or the American Society for Bariatric Surgery.
Medicare will pay for abdominoplasty — also known as a tummy tuck — after weight loss surgery if it is deemed medically necessary because excess skin is causing rashes or infections.
What Is the Prior Authorization Process?
Certain surgeries must now receive prior authorization before Medicare will cover associated costs.
In July 2020, the Centers for Medicare & Medicaid Services put prior authorization requirements in place for certain hospital outpatient procedures “as a method for controlling unnecessary increases in the volume of these services.”
- Vein ablation
- Botulinum toxin injections
According to CMS, the goal of requiring prior authorization is to protect the Medicare Trust Funds from improper payments while still giving patients access to these surgeries for medically necessary reasons.
If prior authorization is not requested in advance for one of these procedures, it will not be covered by Medicare and you won’t be able to appeal the decision.
Prior authorization involves sending medical records to Medicare.
A Medicare Administrative Contractor, or MAC, will then review the records and determine whether the procedure is medically necessary. A MAC is a private contractor who processes Medicare claims.
Prior authorization claims are usually processed within 10 days.
Before you undergo one of the outpatient procedures listed above, make sure to ask your doctor if prior authorization has been requested on your behalf.
9 Cited Research Articles
- Centers for Medicare & Medicaid Services. (2020, July 16). Prior Authorization for Certain Hospital Outpatient Department (OPD) Services. Retrieved from https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services
- Bustillo, A. (n.d.). Guide to Medicare and Reconstructive Surgery. Retrieved from https://www.drbustillo.com/miami-plastic-surgeon/guide-medicare-surgery
- Centers for Medicare & Medicaid Services. (n.d.). Billing and Coding Guidelines for Cosmetic and Reconstructive Surgery LCD. Retrieved from https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34698_20/L34698_GSURG032_BCG.pdf
- Centers for Medicare & Medicaid Services. (n.d.). National Coverage Determination (NCD) for Bariatric Surgery for Treatment of Morbid Obesity (100.1). Retrieved from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=57&bc=AgAAgAAAAAAA&ncdver=3
- Centers for Medicare & Medicaid Services. (n.d.). Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services: Frequently Asked Questions. Retrieved from https://www.cms.gov/files/document/opd-frequently-asked-questions.pdf
- Mayo Clinic. (n.d.). Bariatric Surgery. Retrieved from https://www.mayoclinic.org/tests-procedures/bariatric-surgery/about/pac-20394258
- Medicare.gov. (n.d.). Bariatric surgery. Retrieved from https://www.medicare.gov/coverage/bariatric-surgery
- Medicare.gov. (n.d.). Cosmetic surgery. Retrieved from https://www.medicare.gov/coverage/cosmetic-surgery#:~:text=Medicare%20usually%20doesn't%20cover,of%20a%20malformed%20body%20part.&text=You%20pay%20100%25%20for%20non,services%2C%20including%20most%20cosmetic%20surgery
- Medicare.gov. (n.d.). Outpatient hospital services. Retrieved from https://www.medicare.gov/coverage/outpatient-hospital-services