Guide to Medicare and Reconstructive Surgery
Insurance is always tricky to navigate, but Medicare, in particular, causes a great deal of confusion among consumers. With four parts, deadlines, copayments, and more to consider, it is easy to feel overwhelmed attempting to navigate through the details of what Medicare does and does not do for you.
Medicare can be especially tricky when it comes to plastic and reconstructive surgery. While purely cosmetic procedures are never covered, many popular cosmetic surgeries are covered when they are done for medical reasons. Many procedures that treat health problems while also improving a patient’s appearance will also be covered.
This guide will help you navigate through the intricacies of Medicare coverage when it comes to reconstructive surgery and plastic surgery procedures that are often covered, including the eligibility requirements you must meet for the procedure to be covered.
What is Medicare?
Medicare is a federal health insurance program for Americans who are 65 or older, as well as certain younger people with qualifying disabilities and individuals with End-Stage Renal Disease. Medicare was signed into law by President Johnson in 1965 to help older Americans pay for medical expenses, and it has been expanded many times over the years to over more people.
Medicare has different parts, which cover specific services. Medicare Part A is hospital insurance that covers hospital stays, some home health care, hospice, and care in a skilled nursing facility. Medicare Part B is medical insurance that offers coverage for some outpatient care, medical supplies, preventative care, and doctor’s care. Medicare Part C is a Medicare Advantage Plan, which is a type of health plan offered by a private company that has a contract with Medicare to provide Part A and B benefits. Medicare Part D is a prescription drug coverage program established by President George W. Bush in 2003.
Medicare may be used as a sole health insurance coverage or as companion coverage along with additional insurance received through a spouse, employer, or former employer.
Reconstructive or Aesthetic Surgery Under Medicare
If you are admitted for covered surgery, you will pay Medicare Part A before Medicare pays for anything. From there, Medicare Part A pays the full amount of allowed inpatient hospital charges for up to 60 days. Medicare Part B will pay 80% of the approved amount for doctor’s fees for performing the surgery and all related outpatient care that is not performed at the hospital’s outpatient department. If a covered procedure is performed or any related care provided in an outpatient department at the hospital, the patient may be required to pay the hospital a co-payment above the approved amount.
For the surgery to be paid by Medicare, the procedure must be performed by a healthcare provider who participates in Medicare and it must be “medically necessary,” which means it was ordered or prescribed by a licensed physician or health care provider, and that Medicare agrees the care is necessary.
Medicare will pay:
- To reconstruct one or both breasts following a mastectomy due to cancer
- To improve the function (not the appearance) of a body part that has not developed or formed
- To make repairs following an accidental injury
The following are the most common plastic surgery procedures that may be covered by Medicare.
One common surgery paid for by Medicare is blepharoplasty or eyelid surgery. Typically a cosmetic procedure, Medicare will pay for the surgery for patients with sagging eyelids that are significantly hindering vision.
Medicare covers breast reduction procedures that meet their guidelines. Unlike traditional insurance plans, Medicare does not have a pre-approval system, which means the surgeon will be unable to determine if the breast reduction will be considered medically necessary prior to performing the work. Patients will be informed prior to surgery that they may be responsible for anesthesia and hospital charges if Medicare does not pay.
Some patients may benefit from a reduction but their procedure is considered “borderline,” which means a small amount of tissue is removed relative to the patient’s weight and height, which may get the claim from Medicare denied. Patients who clearly meet Medicare’s guidelines are expected to have the procedure covered.
A reduction mammoplasty will be covered if there is documentation of at least one of the following:
- Symptomatic back, neck or shoulder pain from large breasts that is not helped by 6 months of medical treatment.
- Significant arthritic changes in the upper thoracic or cervical spine.
- Intertriginous maceration or infection of the inframammary skin refractory.
- Permanent shoulder grooves with skin irritation due to the weight of the breasts and bra straps.
Additionally, there must be symptoms resulting from the enlarged breasts that have not responded to non-surgical intervention and the expected amount of tissue to be removed meets specific guidelines.
The procedure may also be approved if it is done to improve symmetry following mastectomy on one breast.
Weight Loss Surgery
Medicare will pay for weight loss surgery, or bariatric surgery, which can help patients lose a significant amount of weight. Medicare pays for three types of procedures:
- The Roux-en-Y bypass, which uses surgical staples to create a pouch in the stomach that is connected to the bowl to bypass most of the stomach.
- Open and laparoscopic biliopancreatic diversion. This surgery bypasses a large amount of the small intestine, diverting digestive juice from the liver and pancreas to the lower intestine.
- Laparoscopic adjustable gastric banding. This procedure uses an adjustable band to pinch off some of the stomach.
Medicare usually requires candidates participate in a six-month supervised weight loss program through a bariatric surgeon or primary care doctor before they pay for surgery. Medicare beneficiaries may be a candidate with a BMI of 35 and at least one health problem related to obesity.
Many patients who undergo weight loss surgery are left with a substantial amount of excess skin. The only way to treat this is through plastic surgery. Medicare will pay for abdominoplasty (or a tummy tuck) after weight loss surgery if it is deemed medically necessary due to excess skin that causes rashes or infections.
Examples of additional plastic surgery procedures that may be covered by Medicare include:
- Treatment of actinic keratosis
- Lipectomy and suction assisted-lipodectomy with the excision of excess skin
- Gynecomastia: If tissue removed is mostly fatty tissue, the procedure is considered cosmetic and not “true” gynecomastia.
- Dermal injections to treat facial lipodystrophy syndrome (LDS)
- Septoplasty or rhinoplasty: Nasal surgery is not covered when its sole function is to improve the patient’s appearance without functioal abnormalities.
- Facial reconstruction surgery following an accident
- Plastic surgery to treat burns
Medicare will not cover surgery performed solely for cosmetic purposes. While plastic and reconstructive surgery can be covered under some cases, its purpose must be to restore function, even if it does offer cosmetic benefits. For example, plastic surgery to treat facial burns following a car accident will be covered, even though this procedure improves the patient’s appearance.
Medicare in Florida
11 of the 20 highest Medicare billers in 2008 were located in Florida, in part due to the high number of senior citizens in the state. The state also has a unique program called Florida SHINE (Serving Health Insurance Needs of Elders). This free program, offered by the Florida Department of Elder Affairs, offers trained volunteers who provide one-on-one counseling and information on Medicare.
There are currently 86 Medicare Advantage Plans in Miami-Dade County, while the state as a whole has 6 Medicare Advantage Plans that are among the highest rated in the country. High-rated plans in the county include AvMed Medicare and Humana Medical Plan, Inc.
“Learning What Medicare Covers and How Much You Pay.” Centers for Medicare & Medicaid Services. October 2010. http://www.medicare.gov/Pubs/pdf/11472.pdf
“Medicare & You.” Centers for Medicare & Medicaid Services. 2014. http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf