Is Plastic Surgery Covered by Medicare?

Cosmetic surgery isn’t all about vanity or keeping up with the Kardashians. For many people, improving their looks is critical to their emotional and mental health and well-being, especially when they are living with what most people would consider a physical defect as opposed to wanting a facelift to look younger or a nose job to appear more attractive. Nevertheless, getting insurance companies to cover a procedure that is considered cosmetic rather than therapeutic is an uphill battle to say the least, and Medicare is no different in this regard. At the crossroads between cosmetic and therapeutic, however, there lie some hard cases, and it might be worthwhile to fight your insurance company for coverage. They might even be acting in bad faith and labeling a procedure cosmetic when they know better.

When Cosmetic Surgery Is Covered by Medicare and When It Isn’t

According to the official Medicare website, “Medicare usually doesn’t cover cosmetic surgery unless you need it because of accidental injury or to improve the function of a malformed body part.” For instance, “Medicare covers breast prostheses for breast reconstruction if you had a mastectomy because of breast cancer.” Part A covers a surgically implanted breast prostheses following a mastectomy if the surgery takes place in an inpatient setting. If the surgery is outpatient, then Part B applies. Part B also covers external breast prostheses following a mastectomy, such as a post-surgical bra. The patient pays 20% of the Medicare-approved amount for the doctor’s services and external breast prostheses, subject to the Part B deductible.

Other hospital outpatient surgeries and procedures that might or might not be considered cosmetic require prior authorization before receiving the service. If the service is considered cosmetic, it won’t be covered, and you would have to pay 100% of the cost. Medicare requires prior authorization for any of the following:

• Blepharoplasty – Surgery to correct droopy eyelids or excess or fatty tissue
• Botox injections – Injections to reduce the appearance of wrinkles would be cosmetic, but injections to treat muscle spasms and twitches likely would be covered.
• Panniculectomy – This surgery removes the pannus or “apron,” an abnormal layer of excess tissue and skin around the lower abdomen. This procedure might result in a flatter abdomen, but it doesn’t tighten the abdominal muscles like a tummy tuck does. Tummy tucks are plastic surgery, whereas panniculectomies are not, provided you receive prior authorization.
• Rhinoplasty – Rhinoplasty is the unfortunate medical term for a nose job. Cosmetic nose jobs aren’t covered, but rhinoplasties are often performed to correct a deviated septum or breathing issue.
• Vein ablation – This surgical procedure uses heat energy to cauterize and close off varicose veins. Varicose veins are unsightly, but they can also be painful and cause irritation and swelling. Vein ablation is an accepted treatment to relieve varicose vein symptoms and their more serious complications, such as blood clots or ulcers.

Private insurance companies can be harder to deal with than Medicare when it comes to surgeries that might be deemed cosmetic. One recent example has been the fight over treatment for Lipedema. Lipedema is a painful, debilitating and progressive adipose tissue disorder that causes rapid and disproportionate growth of fat cells in the legs. One recognized treatment of lipedema is a specialized form of liposuction, but insurance companies tend to issue blanket denials of any request for liposuction, assuming automatically that the procedure is cosmetic. Insurance companies hide behind policy language and official-sounding Clinical Policy Bulletins to justify their blanket denials, but any coverage or claim denial that does not include an individualized assessment of the patient’s needs should raise eyebrows and likely be challenged.

Another battle in recent years has been fought over surgery to remove excess skin after bariatric weight loss surgeries such as gastric bypass or stomach stapling. The morbidly obese (overweight by 100 pounds or more) are at risk of a host of life-threatening illnesses, including heart disease, stroke, diabetes and cancer. These individuals can greatly benefit from bariatric surgery, but patients are left with many pounds of excess skin after the procedure. This excess skin not only affects appearance but also hampers function, movement and mobility and creates the risk of developing painful sores.

State law can come to the aid of patients in these instances. For instance, California’s Health & Safety Code section 1367.63 requires health plans to cover reconstructive surgery that is necessary to improve function or create a normal appearance to the extent possible. This requirement can apply to any “surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.” Section 1367.63 should apply equally to a surgery to remove excess skin as it would to a skin graft for a victim of a burn injury. It’s up to the doctors to decide what a patient needs on a case-by-case basis, and insurers shouldn’t be allowed to ignore the medical professionals with a blanket denial.