Plastic surgery includes both reconstructive and cosmetic treatments. While many believe Medicare never covers these procedures, the program does provide coverage for plastic surgery determined to be medically necessary. Medicare generally does not cover elective procedures for purely aesthetic reasons. Understanding the rules for coverage is the first step, followed by knowing how to locate providers and navigate the financial aspects of care. This article clarifies the distinctions Medicare uses to determine coverage and provides practical steps for finding a plastic surgeon who accepts Medicare for covered services.
Reconstructive Versus Cosmetic Procedures
Medicare coverage for plastic surgery depends entirely on whether the procedure is deemed medically necessary. Reconstructive surgery restores function or corrects the appearance of a body part abnormal due to a congenital defect, trauma, disease, or infection. The goal of reconstructive surgery is to restore normal function or appearance, and these procedures are typically covered by Medicare Part A or Part B.
Cosmetic surgery, conversely, is performed solely to improve appearance for aesthetic reasons and is not covered by Medicare. For instance, a purely cosmetic facelift or rhinoplasty done only to change the shape of the nose is excluded from coverage. However, the same procedure may be covered if it is tied to an underlying medical issue, which often blurs the distinction between the two categories.
Covered reconstructive surgery includes breast reconstruction following a mastectomy for cancer. Eyelid surgery, known as blepharoplasty, is also covered if drooping skin impairs the patient’s vision. In these cases, the surgery is medically necessary because it addresses a functional impairment or restores the body after disease.
Medicare also covers procedures meeting specific functional criteria, such as reduction mammaplasty (breast reduction surgery). This procedure may be covered if the breast tissue causes documented, persistent symptoms like back pain, neck pain, or skeletal deformities. These cases are often evaluated using standardized criteria like the Schnur scale.
Locating Plastic Surgeons Who Accept Medicare
Once a procedure is confirmed as medically necessary, the next step is finding a plastic surgeon who accepts Medicare coverage. The official federal tool, Medicare Care Compare, is the best starting point for searching for physicians and clinicians enrolled in Medicare. This online resource allows beneficiaries to search by specialty and location to find providers in their area.
Understanding the three primary provider statuses is important, as they affect your financial liability. A participating (PAR) provider accepts assignment on all claims, meaning they accept Medicare’s approved amount as payment in full. You are responsible only for the annual deductible and the standard 20% coinsurance for covered services.
A non-participating (Non-PAR) provider accepts Medicare but does not always accept assignment. If a Non-PAR provider does not accept assignment, they can charge up to 15% more than the Medicare-approved amount, known as the limiting charge. You are responsible for the 20% coinsurance plus the 15% limiting charge, totaling up to 35% of the Medicare-approved amount.
An opt-out provider has chosen not to accept Medicare at all and enters into a private contract with the patient. Medicare will not pay for any services from an opt-out provider, and the patient is responsible for the entire cost.
Although the Care Compare tool is helpful, always call the plastic surgeon’s office directly. This confirms their current participation status and verifies if they are accepting new Medicare patients.
Patient Costs and Financial Obligations
Even when Medicare covers a reconstructive procedure, the patient will still have out-of-pocket costs. Original Medicare requires the patient to meet the annual Part B deductible before coverage begins. For 2025, the Part B deductible is $257.
After the deductible is met, the patient is responsible for 20% of the Medicare-approved amount for the procedure. If the procedure requires an inpatient hospital stay, the patient is responsible for the Part A deductible ($1,676 per benefit period in 2025). The patient must also pay costs for any services explicitly excluded from Medicare coverage.
If the medical necessity of a procedure is uncertain, the surgeon may require the patient to sign an Advance Beneficiary Notice of Noncoverage (ABN). This form informs the patient that Medicare may deny payment, making the patient financially responsible. The ABN is used when a normally covered procedure might be deemed not medically necessary, such as a borderline blepharoplasty.
Patients enrolled in a Medicare Advantage (Part C) plan may have different out-of-pocket costs, such as fixed co-pays instead of coinsurance percentages. These private plans must cover all the same medically necessary services as Original Medicare. They often have their own specific network requirements and cost-sharing structures, so consult the specific plan documents.