Medically Necessary Cosmetic Procedures
In many cases, the main and only focus of cosmetic surgery involves improving appearance.
For example, a rhinoplasty, also known as a nose job, may straighten a crooked nose or remove a bump.
Medicare will not cover a rhinoplasty when is it performed only for the improvement of appearance.
However, sometimes a person may experience difficulty breathing, and a nose job could be medically necessary to improve function.
Although a cosmetic benefit may occur as a result of the surgery, the main reason for the procedure is to improve the functioning of the nose.
In this case, if a cosmetic procedure is medically necessary, Medicare provides coverage.
Will Medicare Cover Face Surgery
Plastic surgery is very common after significant weight loss and is generally covered by Medicare. This is because there are valid medical reasons as to why the surgery is necessary.
Excess skin can not only interfere with regular activities and day-to-day living but it can also cause skin irritation, rashes and sores. Surgery relating to the removal of redundant abdominal skin and fat as a direct result of large-scale weight loss is usually on the MBS.
This can also include radical abdominoplasty and other related procedures. However, in order for you to be eligible for cover, your weight must have been stable, for at least six months prior to surgery.
Cosmetic Vs Medical Surgery: A Significant Difference
It will be useful to distinguish between two forms of plastic surgery before we begin our exploration:
- Cosmetic surgery a procedure carried out for purely esthetic purposes .
- Medical plastic surgery surgery needed by an injury or to enhance a malformed body parts function .
Surgery that is solely cosmetic has never been covered or qualified for a Medicare rebate. That didnt shift. What has changed is the way the MBS categorizes different surgeries and the eligibility requirements. Any surgeries were excluded from the list entirely.
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 surgeriesare covered when they are done for medical reasons. Many procedures that treat health problems while also improving a patients 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 Are Your Expectations
You are more likely to be happy with the results of cosmetic surgery if you have clear, realistic expectations and a clear understanding of why you want to have surgery. Your doctor can tell you if your goals are realistic and how best to achieve them.
Get the facts about what to expect from a certain procedure. Have your doctor show you photographs and explain the possible results. With some types of surgery, the final results may not appear for several weeks or months after the procedure. It may take several sessions or a combination of procedures to achieve the look you want. And results are not always permanent.
Remember that the effects of time, gravity, aging, and sun exposure continue after cosmetic surgery. Getting proper nutrition and regular exercise, guarding against sun exposure, managing stress, not smoking, and avoiding drugs and excess alcohol can go a long way toward helping you look and feel young and healthy.
Talking with someone who has had cosmetic surgery may raise issues that you had not considered. Ask how the person felt about the results, whether the surgery achieved the results hoped for, and what the total experience was like. Doctors who have experience with cosmetic surgery can also provide perspective on the issues involved.
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Whats The Difference Between Cosmetic And Plastic Surgery
To begin with, its important to understand that cosmetic surgery and plastic surgery are not the same thing1, even though many of us use these terms interchangeably.
Cosmetic surgery is just one aspect of plastic surgery1. Plastic surgery encompasses both cosmetic surgery and reconstructive surgery. Heres how the Australian Society of Plastic Surgeons defines cosmetic surgery and reconstructive surgery2:
Cosmetic surgery: is designed to improve a persons aesthetic appearance by altering or reshaping a bodily feature.
Reconstructive surgery: is concerned with improving bodily function and performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumours, or disease.
Cosmetic surgery is not medically necessary3 , whereas non-cosmetic plastic surgery involves treatments that are considered to be medically necessary.
How Much Does Plastic Surgery Cost With Medicare
Even if Medicare covers your plastic surgery, there are some out-of-pocket costs you should expect to pay, depending on where you receive your surgery.
- For example, if you undergo surgery for breast prostheses after a mastectomy, your Medicare Part A hospital insurance would cover your hospital costs if the surgery takes place in an inpatient hospital setting.
The Medicare Part A deductible is $1,364 per benefit period in 2019.
The Part A deductible is not annual, and you could experience more than one benefit period in a given calendar year.
After you meet your Part A deductible in a benefit period, you could face Part A coinsurance costs for an inpatient hospital stay that lasts longer than 60 days .
- If your surgery takes place in an outpatient setting, Part B will help cover your plastic surgery costs.The Medicare Part B deductible is $185 per year in 2019.After your Part B deductible is met, you typically pay 20 percent of the Medicare-approved amount for most doctors services.
There is no annual limit on how much you could pay for the Part B coinsurance in a given year.
We recommend speaking with your doctor directly for specific cost and coverage information.
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When Does Medicare Pay For Plastic Surgery
Medicare may cover plastic surgery if it is a reconstructive procedure performed on an area of the body that is malformed or damaged due to injury or an operation. The goal of the cosmetic surgery is to restore a normal appearance and/or function.
Plastic surgery is typically only covered by Medicare if it is for an approved condition, such as:
- Breast reconstruction following mastectomyBreast reconstruction and external breast prostheses are typically considered eligible for Medicare coverage following cancer treatment.
- Accidental injuryAccidental injuries that have caused trauma or damage to a body part may be approved for plastic surgery covered by Medicare.For example, if you are in a car accident and suffer damage to your eye, Medicare may cover necessary plastic surgery to restore the appearance and function of the affected eye.
- MalformationPlastic surgery to fix malformed body parts may be covered by Medicare if they are deemed medically necessary by your doctor.
Medicare does not provide any coverage for selective plastic surgery. You will have to pay 100% of the costs out of pocket for selective comsetic surgeries, such as:
- Breast enlargement
Answer: Mohs Closure Coverage
In my experience, the closures to MOHs surgery are covered by medicare. You may have to pay an additional copay etc. You should be able to call your representative .You always want to keep in mind that this is your FACE. A good closure is important to prevent you from looking like you a skin cancer resected for years to come. Hope this helps and God Bless!Dr. Robb
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Medicare Coverage For Plastic Surgery
Medicare coverage for plastic surgery is likely in medically necessary situations. If the surgery is cosmetic, you pay out of pocket. If the surgery is essential, Part B pays 80% of the cost after you meet the deductible. However, if you just want to make changes to looks, you pay out of pocket.
Will Medicare Cover My Body Contouring Surgery After Massive Weight Loss
In order to qualify for a Medicare rebate for body contouring surgery after massive weight loss, you need to have lost at a minimum, 5 BMI points typically 15kg or more for an average person. Youll need to have maintained this weight loss by keeping at a stable weight for at least 6 months. You must suffer skin conditions which have been treated using non-surgical methods for 3 months with minimal improvement. And, you need to be able to prove that this excess skin following weight loss interferes with your daily activities including exercise. The following item numbers apply
Lipectomy, wedge excision of abdominal apron that is a direct consequence of significant weight loss, not being a service associated with a service to which item 30168, 30171, 30172, 30176, 30177, 30179, 45530, 45564 or 45565 applies, if:
there is intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional treatment and
the abdominal apron interferes with the activities of daily living and
the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy
for Arm Lift and Thigh Lift surgery:
Lipectomy, wedge excision of redundant non abdominal skin and fat that is a direct consequence of significant weight loss, not being a service associated with a service to which item 30165, 30168, 30172, 30176, 30177, 30179, 45530, 45564 or 45565 applies, if:
for Tummy Tuck surgery:
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Which Cosmetic Surgery Procedures Are Usually Covered
Here are a few common procedures that are often covered by health insurance. Its important to note that many other procedures, such as ear surgery and even teeth-straightening, may also be covered in certain circumstances.
- Breast reduction surgery
To qualify for reduction mammoplasty, the patient and her doctor must be able to show that large breasts have hindered her ability to perform certain physical activities, or that they have subjected her to physical pain back and shoulder pain are the most common.
In order to address the physical symptoms associated with large breast size, surgery may be necessary. Just like all semi-cosmetic procedures, whether or not a reduction will be fully covered differs from company to company and plan to plan.
Breast reconstruction or a breast lift may be necessary for optimal results in addition to the reduction. In such scenarios, its common for the insurance company to pay for the reduction, but not the lift. Of course, when a patient has breast cancer, breast reduction or mastectomy surgeries are often medically necessary.
- Upper eyelid surgeries
As mentioned above, if drooping eyelids hinder a patients ability to see and vision tests prove this to be the case then blepharoplasty is often medically necessary. For this reason, eyelid surgery is one of the most common cosmetic procedures to be covered by insurance.
- Weight loss surgery
- Excess skin removal
- Gender reassignment surgery
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How To Apply For A Medicare Rebate
In Australia, all plastic surgeons who are registered with the Australian Society of Plastic Surgeons are recognised by Medicare. This gives them the authority to determine your eligibility for an MBS item number rebate. To receive a Medicare rebate for a medically indicated procedure, first, you must ensure that your procedure is listed on the MBS and you have a valid referral from a GP to attend your specialist. Then, during your initial consultation, you will discuss your concerns with Dr Doyle and based on his understanding of the MBS, he will decide if you qualify for Medicare funding. If this is the case, evidence surveys and photos will be collected and stored on your file. If Medicare raises any concerns regarding your rebate, the Doyle team will provide this evidence as part of your claim.
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Cosmetic Vs Plastic Surgery
Before we get into the nitty-gritty details of how the health insurance plans deal with these procedures, lets make one thing clear: cosmetic and plastic surgery are not the same thing.
That may surprise you, especially since many people use the two words interchangeably. Not that you can blame them. When cosmetic procedures first became common, everybody called them plastic.
Although its hard to say what caused that confusion, the most likely answer is a number of plastic surgeons at the time decided to focus on helping patients with cosmetic rather than reconstructive issues.
Today, people who work in these fields disciplines consider them very different beasts.
What Are The Out
There are some outpatient plastic surgery procedures that are covered by Medicare, such as rhinoplasty. These outpatient procedures are done in an outpatient clinic, and you can return home the same day as the surgery.
However, most medically necessary plastic surgery procedures are inpatient procedures. These procedures require overnight hospitalization. Some examples of inpatient plastic surgery procedures that Medicare may cover include:
- cleft lip or palate surgery
- facial augmentation
- prosthetic or tissue flap breast reconstruction
- upper or lower limb surgery
Whether you require inpatient or outpatient surgery, here are some of the out-of-pocket costs you may encounter, depending on your coverage.
Tips For Getting Covered
If you think you may be a candidate for insurance-funded cosmetic plastic surgery, a good surgery center will work with your medical insurance to help you make a solid case.
Make it clear to your doctor and the insurance company that you have tried other measures such as weight loss, physical therapy, and pain treatment options before resorting to surgery. This will help your insurance provider see the surgery as a last resort, which will make them more likely to cover it.
Medical documentation is also a very important part of the process. Make sure you keep records stating every health change youve made as well as all the times you visited your doctor in search of a solution.
See An Experienced Surgeon
Dr. Neumeister advises asking the surgeon how many cases they do. âYou want expertise. If they say theyâve done one before, you want another opinion if someone has more experience,â he says.
That said, experience isnât everything. Dr. Neumeister explains you may click well with a surgeon and feel very comfortable with them. You may find a surgeon that did 50 procedures in the last year or someone who is just fantastic and has an excellent reputation.
What matters most is that youâre comfortable with your surgeon.
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Do I Need Plastic And Reconstructive Surgery As Part Of My Health Insurance Policy
We can never tell what might happen to us in the future – and if you find yourself in a situation where you need plastic surgery, such as after an accident, knowing its covered by your health insurance can give you much-needed peace of mind.
Over 1,600 surgical procedures are listed under the plastic and reconstructive surgery category in the Medicare Benefits Schedule4, so if your policy doesnt cover you for these treatments – or if there are exclusions or restrictions – it could pose a problem if surgery becomes medically necessary for you.
Facial Surgery Procedures Eye / Ear
42590 Canthoplasty, medial or lateral
45617 Upper eyelid, reduction of, if: the reduction is for any of the following: skin redundancy that causes a visual field defect or intertriginous inflammation of the eyelid herniation of orbital fat in exophthalmos facial nerve palsy post-traumatic scarring the restoration of symmetry of contralateral upper eyelid in respect of one of the conditions mentioned in subparagraphs to and photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes
45659 Correction of a congenital deformity of the ear if: the patient is less than 18 years of age and the deformity is characterised by an absence of the antihelical fold and/or large scapha and/or large concha and photographic evidence demonstrating the clinical need for this service is documented in the patient notes
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