Medicare Reconstructive and Cosmetic Surgery Benefits

Medicare advisors often get questions about Medicare benefit.

Here’s one that came up as we entered the new year…

The Question

What are the differences between cosmetic and reconstructive surgery, and how does Medicare cover these procedures?

The Answer

With 2024 upon us, understanding the nuances of Medicare coverage, particularly in the realms of cosmetic and reconstructive surgery, is crucial for beneficiaries considering such procedures.

An important point is whether the procedure is medically necessary.

Cosmetic surgery: This surgery type enhances visual appearance by reshaping normal body structures. Generally, Medicare does not cover cosmetic surgery unless it’s necessary due to accidental injury or for improving the function of a malformed part of the body. Note: Breast surgery performed for aesthetic reasons without any underlying medical necessity typically falls outside of the scope of coverage.

Reconstructive surgery: Contrastingly, reconstructive surgery aims to restore function, correct deformities, or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. These surgeries are usually deemed medically necessary and are more likely to be covered by Medicare. Examples include reconstructive breast surgery after a mastectomy for breast cancer, nasal surgery to correct congenital or trauma-induced deformities, and gynecomastia treatment in men when medically indicated.

Specific Medicare coverage criteria for various reconstructive procedures include:

1. Breast surgery: Medicare covers reconstructive breast surgery post-mastectomy for breast cancer or other medical conditions. This includes surgeries to restore symmetry or correct congenital abnormalities.

2. Reduction mammaplasty: This procedure is covered if it aligns with the Schnur scale criteria, evaluating the individual’s body surface area and the weight of breast tissue to be removed.

3. Gynecomastia treatment: Surgical intervention for gynecomastia in men is covered when certain criteria are met, including severity as per the American Society of Plastic Surgeons’ gynecomastia scale.

4. Nasal surgery: Reconstructive nasal surgery, including rhinoplasty, is covered when performed to improve nasal respiratory function, correct birth defects, disease-related deformities, or structural deformities caused by trauma.