Is Cosmetic Surgery Covered by Medicare?

Most insurance companies do not pay for cosmetic surgery and Medicare is no exception. Of course, it gets more complicated when a procedure that is considered cosmetic is performed for medical reasons. Where does Medicare draw the line?

Medicare Coverage for Surgeries

Medicare classifies surgical procedures as inpatient or outpatient. The Centers for Medicare & Medicaid Services (CMS) releases a list of inpatient only (IPO) procedures every year. These procedures are more surgically complex, at higher risk for complications, and require close post-operative monitoring. They are covered by Medicare Part A.

Any procedure that is not on the IPO list is an outpatient procedure and is billed to Medicare Part B. An outpatient procedure could be considered for an inpatient hospital stay if the patient has underlying medical conditions that increase their risk for complications, has surgical complications, or has post-operative problems.

Regardless of the procedure, Medicare will not cover it if it is not considered medically necessary. That is where cosmetic procedures come into play. You are likely to pay out of pocket for a procedure performed for aesthetic reasons. However, Medicare may cover plastic surgery in the following situations:

• To reconstruct a breast following a mastectomy for cancer
• To improve the function of a malformed body part (e.g., cleft lip or palate surgery)
• To repair damage after a trauma or accidental injury (e.g., earlobe surgery after a tear)

Changes to Five Types of Surgeries

CMS has raised concerns that Medicare is paying for cosmetic procedures at an increasing rate, more than would be expected based on an increasing number of Medicare beneficiaries (10,000 people are expected to become eligible for Medicare each day through 2030) or on advances in medical treatments.

It is presumed that medical providers may be claiming procedures that are medically necessary when they may not be. To decrease Medicare costs and to preserve the Medicare Trust Fund, they have specifically targeted five categories of outpatient procedures.

Blepharoplasty

What it is: This surgery removes loose skin, muscle, and/or excess fat from the upper and/or lower eyelids.

How often Medicare pays for it: Medicare claims for upper eyelid surgery increased to 49% from 2011 to 2012.

Medically necessary reasons for the procedure: Although blepharoplasty is often used to improve the appearance of the eyes, it can also be used to treat painful spasms around the eye (blepharospasm), to treat a nerve palsy, to improve vision when the upper lid obstructs the eye, to treat complications from another medical condition (e.g., thyroid disease), or to prepare for placement of a prosthetic eye.

Botulinum Toxin Injections to the Face and Neck

What it is: Injection of botulinum toxin, a derivative of the neurotoxin from the bacteria Clostridium botulinum, is used to temporarily relax and/or paralyze muscles.

How often Medicare pays for it: Medicare claims for botulinum injections to the face increased by 19.3% from 2007 to 2017.

Medically necessary reasons for the procedure: Although botulinum injections are often used to reduce the appearance of fine lines and wrinkles, it can also be used to treat muscle spasms in the neck (cervical dystonia) or to decrease the frequency of chronic migraines when other treatments have failed.

Panniculectomy

What it is: This surgery removes the abdominal pannus—excess skin and fat that hangs from the lower abdomen.

How often Medicare pays for it: Medicare claims for panniculectomy increased by 9.2% from 2007 to 2017.

Medically necessary reasons for the procedure: Although a panniculectomy improves the appearance and contour of the abdomen, removal of the tissue may be needed to address recurrent skin infections (cellulitis) and ulcerations over the pannus that have not been effectively treated with other therapies.

Rhinoplasty

What it is: Rhinoplasty is a reconstructive procedure that changes the shape and contour of the nose.

How often Medicare pays for it: Medicare claims for widening of the nasal passages increased to 34.8% from 2016 to 2017.

Medically necessary reasons for the procedure: Although a rhinoplasty, also known as a nose job, is often used to improve the appearance of the nose, it can also be used to correct a congenital defect or traumatic injury that causes a functional impairment or to treat a chronic nasal obstruction that cannot be effectively treated with a less invasive procedure (e.g., septoplasty).

Vein Ablation

What it is: This procedure uses targeted chemical, laser, or radiofrequency treatments to occlude enlarged veins and divert blood to nearby healthy veins.

How often Medicare pays for it: Medicare claims for vein ablation increased by 11.1% from 2007 to 2017.

Medically necessary reasons for the procedure: Although vein ablation is often used to improve the appearance of varicose and spider veins, it can also be used to treat veins that cause skin ulcerations, to decrease the frequency of superficial thrombophlebitis in someone with recurrent symptoms, and to address severe pain and swelling that persists despite medication.

Prior Authorization Process

CMS has put in place a prior authorization protocol for the five categories of outpatient procedures listed above. The protocol began on July 1, 2020 and requires that the hospital receive approval before the procedure is performed. This will involve providing medical records to Medicare for review.

Based on those medical records, a Medicare Administrative Contractor (MAC) will determine whether the procedure is medically necessary. A MAC is a private contractor assigned to process Medicare claims in a designated area of the country.

Referring to established standards of care and guidelines from specialty organizations, each MAC will establish its own definition for what makes a specific procedure medically necessary. Prior authorization requests will be processed by MACs within 10 days, although a request can be expedited for high-risk situations.

A procedure that is deemed medically necessary by the MAC is given an affirmation and should be covered by Medicare. If a prior authorization is requested but is non-affirming, Medicare will deny payment for the procedure but the hospital and any providers can appeal for coverage after the procedure is performed.

It is important to be aware of this prior authorization protocol because it can cost you. If the hospital has not gotten affirmation through a prior authorization for one of these procedures, you could be asked to sign an Advance Beneficiary Notice (ABN).

That would be an acknowledgment that Medicare may not cover the procedure and that you agree to pay out of pocket for all services. Before you sign it, known your rights. Ask if a prior authorization has been requested, if it has been affirmed, and if it is eligible for a Medicare appeal.

To make a decision about a potentially expensive procedure without being given the full disclosure of expected costs is not only unfair, it is unethical.

A Word From Verywell

Medicare does not cover surgeries for cosmetic reasons. If a procedure has a medical indication, however, they may pay for it. If you are going to have a blepharoplasty, botulinum toxin injection to face or neck, panniculectomy, rhinoplasty, or vein ablation, ask your healthcare provider if a prior authorization has been requested before you have the procedure. This will let you know if Medicare will cover it and how much you can be expected to pay out of pocket.