Cosmetic vs Reconstructive Plastic Surgery: What Insurance Covers
How insurers and Medicare separate cosmetic from reconstructive procedures, and what to ask before you schedule.
Plastic surgery covers two broad areas. Cosmetic procedures are chosen to change appearance. Reconstructive procedures aim to restore form or function after injury, illness, surgery or a birth difference. The difference matters because health insurance, including Medicare, generally does not pay for cosmetic surgery but may pay for reconstructive surgery that is medically necessary.
What Medicare says
Original Medicare generally does not cover cosmetic surgery. It may cover reconstructive surgery that is medically necessary, such as repair after an accident or a procedure that restores a function. Medicare's own pages on its coverage explain how to check whether a particular service is covered; start with medicare.gov/coverage and ask the doctor's office to confirm in writing that the procedure and its billing codes are covered before you schedule.
Medicare's page on cosmetic surgery is more specific: Medicare usually does not cover it unless you need it because of an accidental injury or to improve the function of a malformed body part, and it covers breast reconstruction after a mastectomy for breast cancer. For five services that are sometimes, but not always, considered cosmetic, Medicare usually requires prior authorization when they are done in a hospital outpatient department or ambulatory surgical center:
- blepharoplasty (eyelid surgery);
- botulinum toxin injections;
- panniculectomy (removal of excess skin and tissue from the lower abdomen);
- rhinoplasty;
- vein ablation.
Your provider sends the request and the records. If Medicare approves it, you should generally owe only your deductible and coinsurance.
Breast reconstruction after mastectomy
Federal law, the Women's Health and Cancer Rights Act, requires group health plans and individual health insurance policies that cover mastectomy to cover all stages of reconstruction of the breast on which the mastectomy was performed, surgery on the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications. The Department of Labor explains the law. Ask your plan what applies to you, and ask the plastic surgeon's office to help you with prior authorization.
According to CMS, plans must tell you about these benefits when you enroll and every year after. The law does not require a plan to cover mastectomy in the first place, and a self-funded state or local government plan may opt out if it notifies enrollees. If you think your plan is not following the law, CMS's page explains who regulates each type of plan. Medicare is not covered by WHCRA but has its own rules: Part B covers some external breast prostheses, including a post-surgical bra, after a mastectomy.
Prior authorization
Many private plans require approval before a reconstructive procedure, and they may ask for notes, photos and a statement of medical necessity. Ask the surgeon's office whether it submits the request, how long a decision usually takes and what to do if the plan says no. If a claim is denied, you have the right to appeal, and the denial letter explains how.
Gray areas
Some procedures fall between categories. Examples people ask about are eyelid surgery when drooping lids block vision, breast reduction for pain, or nasal surgery to improve breathing. Insurers set their own criteria, and they differ. The only reliable answer is your own plan's written policy and a written confirmation before you proceed.
If it is cosmetic
You will pay out of pocket. Ask for an itemized quote that shows the surgeon's fee, the facility fee, the anesthesia fee, implants or other devices, medications, garments and follow-up visits. Ask what a revision costs if you need one, and what the deposit and cancellation policies are. If you are offered financing, read the interest rate and terms; some medical credit cards charge deferred interest from the first day if you do not repay in time.
When you are paying yourself, you are usually entitled to a written good faith estimate under the No Surprises Act if you schedule at least 3 business days ahead or ask for one. CMS notes that each estimate currently covers a single provider or facility, so for surgery ask for one from the surgeon and one from the facility, and from the anesthesia provider too. If a bill comes in at least $400 above that provider's estimate, you can start a federal dispute within 120 days of getting the initial bill.
Safety comes first
A lower price should not mean a lower standard of safety. Check the license, the board certification and the facility before you decide. See our guide on checking credentials. If you are thinking of traveling abroad for surgery, read the CDC's advice on medical tourism, which describes risks such as infection, complications that are hard to manage at home and limited recourse.
Where this directory fits
We list registry records from the federal NPPES file. A listing says the provider registered with plastic surgery as a specialty. It does not tell you what a provider's procedures cost or what your plan covers, and it is not a recommendation.
Questions to ask your plan
- Is this procedure covered when it is medically necessary, and under which billing codes?
- Do I need prior authorization, and who submits it?
- Do I need a referral from my primary care doctor?
- Is the surgeon and the facility in my network, and what would I owe if they are not?
- What is my deductible and out-of-pocket maximum this year?
- If the plan treats the procedure as cosmetic and denies it, what records would it need to reconsider, and how do I appeal?
Write down the date, the name of the person you spoke with and a reference number for each call. If the plan's answer is different from what you were told by the surgeon's office, ask for it in writing. A written decision is also what you need if you decide to appeal, so keep copies of every letter and explanation of benefits.
General information only, current as of the date above. The information on Plastic Surgery Index is not medical advice and does not replace a doctor, nurse, discharge planner or other qualified professional. Do not use it to make decisions about diagnosis or treatment. If you have a medical emergency, call 911. Rules and programs change; check the official sources linked in this guide.