Does Medicare provide cover for plastic surgery?

If you’ve ever looked in the mirror and thought, “Medicare, buddy… you up?”
you’re not alone. Plastic surgery sits right on the fault line between
medical necessity and looking fabulousand Medicare is pretty strict about which side
it’s willing to pay for.

Here’s the reality: Medicare generally does not cover cosmetic surgery (the “I just want to change my look” category).
But Medicare may cover plastic surgery that’s medically necessaryespecially when the goal is to repair damage,
restore function, or address a congenital issue or disease-related defect.

The short answer (with the least amount of fine print)

Yes, Medicare can cover some plastic surgery. But it’s typically limited to cases where the surgery is needed:

• to repair an accidental injury (like trauma from a fall or car crash),
• to improve the function of a body part (not just its appearance),
• to treat or reconstruct damage caused by disease (like cancer),
• or to address certain birth defects or malformed body parts.

Meanwhile, procedures done solely to enhance appearancethink facelifts, purely aesthetic “nose jobs,” or liposuction for contouringare usually
not covered. Medicare isn’t trying to be mean. It’s just… very committed to being Medicare.

Medicare’s rule: “Cosmetic” vs. “medically necessary”

Medicare draws a bright line between surgery that’s primarily for appearance and surgery that’s primarily for health and function.
In policy language, cosmetic surgery is generally excluded, with exceptions when the procedure is needed to promptly repair accidental injury
or improve the functioning of a malformed body partand when a procedure is therapeutic, it may still be covered even if it also improves appearance.

Translation: If your surgery helps you see, breathe, chew, walk, or healnot just “look better in selfies”you’re in a much stronger
position for coverage.

Plastic surgery isn’t always cosmetic (and Medicare knows that)

“Plastic surgery” is a broad field that includes both reconstructive and cosmetic procedures.
Reconstructive surgery focuses on repairing defects caused by injury, disease, or congenital issues, and it often aims to restore function.
Cosmetic surgery focuses on enhancing appearance in otherwise normal structures.

The tricky part is that some procedures can be either. An eyelid lift might be cosmetic if it’s done to look more awake, but reconstructive
if drooping lids are blocking your vision. Same tools, different purposeand Medicare cares deeply about the purpose.

Examples of plastic surgery Medicare may cover

Coverage is case-by-case, but these are common situations where Medicare is more likely to cover plastic surgery because it’s medically necessary.
(Key phrase: documented medical necessity.)

1) Breast reconstruction after mastectomy

Medicare generally covers breast reconstruction related to a medically necessary mastectomy. Depending on where the surgery happens,
Part A may apply for inpatient hospital care and Part B for outpatient surgery and physician services.
Medicare can also cover certain breast prostheses and post-surgical items in appropriate circumstances.

2) Reconstruction after accidents, trauma, or severe burns

If you need surgery to repair facial injuries after an accident, reconstruct tissue after burns, or correct damage that interferes with function,
Medicare may treat that as covered reconstructive care. The goal here isn’t vanity; it’s restoring normal use and structure after something went wrong.

3) Repair after cancer treatment or tumor removal

Surgery to reconstruct areas affected by cancer treatment can sometimes be covered when it’s part of medically necessary care.
A classic example is reconstruction after removal of skin cancer or other tumors where tissue repair is needed for healing and function.
(This is where people often learn that “reconstructive” doesn’t always mean dramaticit can be as practical as closing a wound properly.)

4) Eyelid surgery when it affects vision (blepharoplasty/ptosis repair)

Eyelid procedures are a frequent “gray area” because they can be cosmetic or functional. Medicare may cover these surgeries when documentation shows
the eyelids are impairing vision or causing other functional problems. In real life, this often involves an eye exam, measurements, and sometimes
visual field testing or photographsbecause Medicare likes proof, not vibes.

5) Panniculectomy when excess skin causes medical problems

A panniculectomy removes excess abdominal skin (often after major weight loss). Medicare typically won’t cover it when it’s mainly for contouring,
but it may be covered if the excess skin causes ongoing medical issueslike chronic rashes, infections, skin breakdown, pain, or functional limitation
and if conservative treatments have been tried and documented.

6) Certain congenital or developmental defects

Repairing a malformed body part or congenital anomaly may be covered when the procedure improves function or addresses medically significant issues.
Again, “medically necessary” and “documented” are the magic words.

Examples Medicare usually does NOT cover

Medicare generally excludes procedures performed primarily to improve appearance. Common examples include:

• Facelifts and neck lifts done for appearance alone
• Purely cosmetic rhinoplasty (“nose job” without functional breathing problems)
• Liposuction for shaping/contouring
• Tummy tucks (abdominoplasty) done for appearance rather than medical complications
• Cosmetic Botox for wrinkles (as opposed to medically necessary injections for certain conditions)
• Procedures primarily for acne scarring or aesthetic skin resurfacing

One important nuance: if Medicare denies the procedure as non-covered, you may also be responsible for related costs
(facility fees, anesthesia, supplies). So it’s worth sorting out coverage before anyone warms up the operating room.

Which part of Medicare pays (and why it matters)

Original Medicare: Part A vs. Part B

Part A (Hospital Insurance) generally applies if you’re admitted as an inpatient. Think hospital stay, room, nursing services, and inpatient facility charges.

Part B (Medical Insurance) generally applies to outpatient surgery, physician services, imaging, and many medically necessary procedures performed without admission.

Even when Medicare covers the procedure, you may still have out-of-pocket costs like deductibles and coinsurance. And yes,
those numbers can feel like they were designed by someone who hates calculators.

Medicare Advantage (Part C)

Medicare Advantage plans must cover the same basic benefits as Original Medicare, but they often run the show differently.
That can include network rules, referrals, and prior authorization. Some plans also offer extra benefits (like dental/vision),
but those extras don’t usually translate into Medicare paying for purely cosmetic surgery.

Medigap and other supplemental coverage

Medigap (Medicare Supplement Insurance) can help with cost-sharing for covered services, but it typically doesn’t turn a non-covered cosmetic procedure
into a covered one. If Medicare says “not covered,” Medigap usually can’t swoop in like a superhero.

Prior authorization: yes, even in Original Medicare (in specific cases)

Medicare now requires prior authorization for certain outpatient services that can be either cosmetic or medically necessarylike
blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablationwhen performed in certain settings.

Hospital Outpatient Departments (nationwide)

There’s a nationwide prior authorization process for these services when provided in hospital outpatient departments. The good news:
the provider is generally responsible for submitting the request and documentation.

Ambulatory Surgical Centers (ASC) demonstration in select states (phased in early 2026)

CMS also launched a prior authorization demonstration for these same categories in ambulatory surgical centers in specific states,
and it was delayed into a two-phase start:

• California, Florida, Tennessee, Pennsylvania, Maryland, Georgia, and New York:
  requests starting January 5, 2026 for dates of service on/after January 19, 2026
• Texas, Arizona, and Ohio:
  requests starting February 2, 2026 for dates of service on/after February 16, 2026

Practical takeaway: if you’re scheduling one of these “could-be-cosmetic” procedures, the location (hospital outpatient department vs. ambulatory surgery center)
can change what paperwork is required before surgery.

What Medicare looks for when deciding coverage

Medicare coverage decisions often come down to one question: Is it reasonable and necessary?
The documentation needs to show that the procedure is treating an illness, injury, or functional impairmentnot simply improving appearance.

Depending on the procedure, that may include:

• A clear diagnosis and description of symptoms (for example, vision obstruction or chronic skin breakdown)
• Evidence of failed conservative treatment (like medications or supportive garments for recurring rashes)
• Objective measurements or testing (like visual field tests for eyelid procedures)
• Photographs, chart notes, specialist consults, and timeline of the condition

Medicare Administrative Contractors (MACs) and local coverage rules can also shape what documentation is needed.
That’s why two people can have similar procedures and get different outcomesbecause the medical story on paper isn’t the same.

How to boost your chances of coverage (without turning your life into a paperwork hobby)

1) Start with the “why,” not the “what”

Ask your surgeon to explain the functional or medical reason for surgery in plain English. Then make sure that reason is also clearly documented
in your medical records. Medicare loves consistency.

2) Ask for the billing codes and setting

Request the procedure codes (often CPT/HCPCS) and confirm where the surgery will happen (office, hospital outpatient department, ambulatory surgery center).
This helps you anticipate prior authorization requirements and likely costs.

3) Make sure conservative treatments are documented

If the surgery is being justified because other options didn’t work, your records should reflect what was tried, for how long, and what happened.
“Tried creams, still miserable” is helpful. “Patient sad about swimsuit season” is not.

4) Get a written cost estimate

Even covered surgeries can leave you with deductibles and coinsurance. Ask for a written estimate that includes surgeon, facility, anesthesia,
and post-op follow-ups. It’s not rudeit’s adulthood.

5) If you have Medicare Advantage, ask about plan rules early

Confirm network requirements, referrals, and whether prior authorization is needed. With many plans, getting approval first is the difference between
“covered” and “surprise, you owe a lot.”

If Medicare denies the procedure: what happens next?

If a provider believes Medicare may deny coverage, you might be asked to sign an Advance Beneficiary Notice (ABN).
This document basically says: “Medicare might not pay. Do you still want to proceedand accept financial responsibility if denied?”

If you disagree with a denial, you can appeal. Appeals are more effective when they include:

• clear documentation of medical necessity and functional impairment,
• supporting test results or photos,
• physician letters explaining why the procedure is needed,
• and proof of failed conservative treatment when applicable.

Bottom line: Medicare covers function, not “fun”

Medicare doesn’t cover most cosmetic surgery, but it can cover plastic surgery when it’s medically necessaryespecially for reconstruction
after trauma, cancer, severe burns, congenital issues, or functional impairment (like vision obstruction).
The deciding factor is almost always the same: medical necessity backed by strong documentation.

If you’re considering plastic surgery and hoping Medicare will help, focus your conversations with your doctor on what the procedure will fix:
pain, infection, impaired movement, blocked vision, breathing issues, or reconstructive needs after illness or injury.
If the “why” is solid, the coverage odds get much better.

Real-world experiences: what this looks like for actual Medicare patients (composite stories)

The rules are one thing; living through the process is another. Here are common experiences people report when navigating Medicare and plastic surgery.
These are composite scenarios (not specific individuals), but they reflect the real patterns that show up again and again in clinics and billing offices.

Experience #1: “My eyelids weren’t just droopythey were blocking my vision.”

One older adult scheduled an upper eyelid procedure after noticing they were raising their eyebrows constantly just to see clearlyespecially while driving.
At first, they assumed it was purely cosmetic and didn’t even mention it to their primary care doctor. But an eye specialist documented reduced
visual fields, took photographs, and noted how the eyelid position interfered with daily activities. The surgeon’s office submitted the documentation
in advance because eyelid procedures can trigger prior authorization requirements in certain outpatient settings. Once approved, the patient still owed
typical Part B cost-sharing, but the biggest relief was psychological: it wasn’t “vanity surgery,” it was “I would like to see the road, thanks.”
The lesson: when function is the issue, get objective testing and make sure your chart tells the story clearly.

Experience #2: “I lost a lot of weight… and then gained a whole new medical problem.”

Another common story involves significant weight loss followed by excess abdominal skin that caused persistent rashes and recurrent infections.
The patient tried topical treatments, careful hygiene, and barrier creams for months. Nothing solved it long-term because the skin folds stayed moist and irritated.
When the surgeon discussed panniculectomy, the patient assumed Medicare would deny it as a “tummy tuck.” The difference came down to documentation:
repeated office visits for skin breakdown, proof that conservative treatments were tried, and notes describing how the condition affected mobility and comfort.
The approval process felt slow, and the paperwork was nobody’s favorite hobby, but the eventual outcome was both medical and emotional: fewer infections,
less pain, and a return to normal daily activities. The lesson: this is one of the clearest examples where medical necessity must be proven on paper.

Experience #3: “Breast reconstruction was part of healing, not an ‘extra.’”

People who undergo mastectomy for breast cancer often describe reconstruction as restoring wholeness after a life-changing diagnosis.
In many cases, reconstruction discussions happen alongside cancer treatment planning. Patients frequently report that Medicare coverage is easier to understand here than
with other plastic surgery questionsbecause reconstruction after mastectomy is widely recognized as medically appropriate care.
The practical experience still includes logistics: whether the surgery happens inpatient or outpatient can affect which part of Medicare applies, and out-of-pocket costs
depend on deductibles, coinsurance, and any supplemental coverage. But compared with “gray area” procedures, patients often feel they have clearer footing and less fear
of an automatic denial. The lesson: some reconstructive categories are more straightforward under Medicare, but you still want cost estimates and clear billing details.

Experience #4: “I wanted a cosmetic changeand Medicare’s answer was basically: ‘That’s nice.’”

Not every story ends with coverageand that’s important to say out loud. Some patients pursue facelifts, cosmetic rhinoplasty, or body contouring purely for appearance.
In those cases, Medicare typically won’t cover the procedure. People often describe surprise at how broad “not covered” can be: not just the surgeon’s fee,
but also anesthesia and facility charges if the entire service is classified as cosmetic. A common moment in these stories is the ABN conversationwhen a provider
explains that Medicare is expected to deny payment and asks whether the patient wants to proceed anyway. Many people do proceed, but they do it with eyes open,
a written estimate in hand, and a plan for payment. The lesson: if the goal is appearance-only, assume you’ll pay 100%and protect yourself with clear pricing
before you commit.