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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The rules say that cosmetic surgery is performed to reshape normal structures of the body in order to improve 
the patient's appearance and self-esteem. Please refer to CMS IOM Publication 100-02, Medicare Benefit 
Policy Manual, Chapter 16: Section 120 for detailed information. 
o Corrective facial surgery will be considered cosmetic rather than reconstructive when there is no 
functional impairment present. However, some congenital, acquired, traumatic or developmental 
anomalies may not result in functional impairment, but are so severely disfiguring (e.g. but not 
limited to severe burns or repair of the face following a serious automobile accident) as to merit 
consideration for corrective surgery. 
o Treatment of complications arising from cosmetic surgery will be considered reasonable and 
necessary as long as infection, hemorrhage or other serious documented medical complication 
occurs, and the beneficiary has been officially discharged from the facility. 
Per the Medicare Benefit Policy Manual cosmetic surgery or expenses incurred in connection with such 
surgery, for the sole purpose of improving ones appearance, is not covered. B. Indications for specific surgical procedure 
o Breast reconstruction of the affected and the contralateral unaffected breast following a 
medically necessary mastectomy is covered. 
o Removal or revision of a breast implant whether placed for reconstructive or cosmetic reasons, 
is considered medically necessary when it is removed for one of the following reasons:
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a. Mechanical complication of breast prosthesis; including rupture or failed implant, and/or 
implant extrusion. 
b. Infection or inflammatory reaction due to a breast prosthesis; including infected breast 
implant, or rejection of breast implants. 
c. Other complication of internal breast implant; including siliconoma, granuloma, 
interference with diagnosis of breast cancer, and/or painful capsular contracture with 
disfigurement. 
o Breast Reduction is the surgical reshaping of the breasts to reduce, or lift enlarged or sagging 
breasts. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare 
benefit. 
Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue 
relative to the general body habitus. Breast hypertrophy may adversely affect other body 
systems: musculoskeletal, respiratory, and integumentary. Unilateral hypertrophy may result in 
symptoms following contralateral mastectomy. 
Local Coverage Determination: Cosmetic and Reconstructive Surgery (L39051). 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.