Medicare does not cover weight loss drugs. Nor does it cover erectile dysfunction drugs due to the 20-year-old Medicare Modernization Act. The blockbuster drugs, Ozempic and Wegovy, are only covered by Medicare if they are prescribed for Type 2 diabetes.
This doesn’t make sense because Medicare does cover very expensive gastric bypass surgery and laparoscopic banding surgery when you meet certain conditions. But to be eligible for lap band surgery, you must be twice your ideal weight or at least 100 pounds overweight.
Medicare may pay for you to have loose skin removed due to extreme weight loss. But if the procedure is wholly cosmetic, it’s not covered. It must be because the extra skin in impacting your health.
Medicare does not pay for any procedure that is purely cosmetic, but sometimes medical necessity and cosmetic benefits align.
Medicare will pay for you to have upper eyelid surgery, known as blepharoplasty. Many retirees have sagging up eyelids that obscure their vision. Proof of a minimum of 12 degrees (or 30 percent) of your visual field must be obstructed for Medicare to pay for this simple surgery. If you are under 65 and on the Affordable Care Act, the rules are similar. Ask your ophthalmologist if you qualify. The unintended cosmetic benefits of an eyelift are a plus. You can see better and you look more youthful.
Medicare will also pay for Botox if medically necessary, usually for migraines or muscle spasms or twitches. Here again, there could also be an unintended cosmetic benefit. Varicose veins also fall into this gray area. If they don’t cause you any pain or discomfort, Medicare will not cover their removal. But many people have vein ablation covered by Medicare due to constant leg pain. Rhinoplasty is another common procedure that people assume Medicare will not cover. But if you are experiencing breathing difficulties that can be alleviated by reshaping your nose, Medicare will pay for your nose job.
Medicare will pay for breast protheses for breast reconstruction from a mastectomy due to breast cancer. Medicare will even pay for mastectomy bras and silicone breast forms.
Most people are shocked to learn that since 2013 Medicare has been paying for gender reassignment surgeries. Medicare will pay as long as it’s deemed medically necessary due to gender dysphoria.
How much you pay out of pocket for any Medicare procedure depends on your type of insurance. Most procedures listed above are subject to deductible and coinsurance. A Medicare Supplement plan can lower your out-of-pocket Medicare costs for many of these procedures.
Sylvia Gordon is co-founder of The Medicare Family, headquartered in Noblesville, where she educates thousands on Medicare and Social Security in all 50 states. You can learn more at TheMedicareFamily.com.