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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 state 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. 
 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. 
 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. 
A. The following procedures are non-covered for the following indications. 
Limitations 
1. Cosmetic surgery performed to treat psychiatric or emotional problems is not covered. 
2. If a non-covered cosmetic surgery is performed in the same operative period as a covered 
surgical procedure, benefits will be provided for the covered surgical procedure only. 
3. Dermabrasion 
 Post-acne scarring 
 Rosacea other than rhinophyma 
 All other indications not identified as covered in the section above 
4. Abdominal Lipectomy/Panniculectomy 
 Repairing abdominal wall laxity, or diastasis recti  Redundancies resulting from weight loss or weight loss surgery when that tissue is 
without evidence of chronic infection or inflammation that is refractory to conservative 
treatment as outlines in the indications listed above. 
 Solely to improve appearance 
 All other indications unless covered in the section above 
Note: Abdominal Lipectomy/Panniculectomy is considered experimental and investigational for 
minimizing the risk of hernia formation or recurrence. There is no evidence that pannus 
contributes to hernia formation. The primary cause of hernia formation is an abdominal wall 
defect or weakness, not a pulling effect from a large or redundant pannus. 
5. Liposuction used for body contouring, weight reduction or the harvest of fat tissue for transfer to 
another body region for alteration of appearance or self-image or physical appearance is 
considered cosmetic and not covered as medically necessary. 
6. Reconstructive Breast Surgery: Removal of Breast Implants for re-implantation of an implant 
inserted for cosmetic purposes only and not for history of mastectomy for treatment of breast 
cancer, lumpectomy, or treatment of contralateral breast to bring it into symmetry with a 
reconstructed breast following cancer surgery is not a covered Medicare benefit. 
7. Reduction Mammaplasty 
 Surgery performed primarily to reshape the breasts to improve appearance or self-image. 
 Mammapexy unrelated to breast reconstruction following a medically necessary 
mastectomy. 
8. Mastectomy for gynecomastia 
 Breast reduction or surgical mastectomy for gynecomastia, either unilateral or bilateral, 
as the first line treatment. 
 When performed solely to improve appearance of the male breast or to alter contours of 
the chest wall. 
9. Gigantomastia of Pregnancy 
 Surgery to reshape the breasts to improve appearance or self-image. 
 All other indications not identified as covered in the section above. 
10. 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 as to merit 
consideration for corrective surgery. These situations will be handled through the appeal 
process. 
11. Thyroid chrondoplasty to alter the appearance of the thyroid cartilage which is without 
functional defect is considered cosmetic. 
12. Rhinoplasty is not covered when performed for either of the following indications because it is 
considered cosmetic in nature or not medically necessary: 
 Solely for the purpose of changing appearance or improving self-image in the absence of 
any signs or symptoms of functional abnormalities. 
 As a primary treatment for an obstructive sleep disorder when the above criteria for 
approval have not been met. 
13. Rhytidectomy is generally considered a cosmetic procedure. It may be considered medically 
necessary upon review to correct a functional impairment as a result of a disease state ie; facial 
paralysis. Often this procedure is performed in conjunction with other procedures to correct the 
impairment. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L39051: Cosmetic and Reconstructive 
Surgery. 
 The rules say that cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.