Rhinoplasty, breast augmentation,hymenoplasty…
During your consultation with your surgeon, we always check whether you are eligible for reimbursement from Medicare and your private health insurance.

Before addressing the issue of reimbursement, it is important to note the difference between cosmetic surgery and plastic surgery, as the answer varies.

Cosmetic surgery and reconstructive plastic surgery: what's the difference?

• Reconstructive Plastic Surgery

This is a type of surgery designed to correct physical disfigurement. Reconstructive plastic surgery may be performed following a serious accident, as well as in cases of illness, such as breast cancer requiring a mastectomy (removal of the breasts). In the case of a congenital malformation, such as being born with a cleft palate. In short, it involves repairing congenital defects or injuries that have been caused to the body. 

It should be noted that surgery performed to correct the results of a previous botched cosmetic procedure is not considered reconstructive plastic surgery. 

• Cosmetic surgery

Cosmetic surgery is primarily a decision based on your own aesthetic preferences. It is therefore a purely personal choice, not motivated by medical reasons. This includes procedures such as breast augmentation, facelifts, liposuction, etc.

In short, the goal is to help you feel good about yourself by enhancing your appearance according to your own personal standards.
Social Security strictly regulates the reimbursement of procedures, whether plastic surgery is performed abroad or in France

Let’s get back to the main topic: plastic surgery covered by Medicare

Yes: there are plastic surgery procedures covered by Medicare.

Let’s take a look at the financial assistance available from Social Security and private health insurance providers depending on the type of reconstructive plastic surgery you’re seeking.

Just because Social Security covers a procedure doesn’t mean it’s free or that it won’t cost you anything.

This means that the procedure is intended to treat a medical condition, which will require medical care and may necessitate sick leave.
Care in a private facility will be provided by a private surgeon and anesthesiologist.
The plastic surgeon will provide aquote that includes their feesas well as those of the anesthesiologist.

To be eligible for a partial or full refund, you must have private health insurance

And choose a plastic surgeon who accepts Medicare.
Send this estimate to your private health insurance provider (if you have one) before the surgery to find out how much you’ll have to pay out of pocket after reimbursement.
Some private health insurance plans offer very good coverage, even covering the full cost of medical fees.
Others provide insufficient coverage.

Two scenarios for reimbursement of plastic surgery procedures (this list is not exhaustive)

1. Procedures that are always covered by Social Security and mutual insurance companies (direct coverage)

In such cases, the board-certified plastic surgeon provides a quote for reconstructive surgery directly:

Breast reduction

• At least 300 grams must be removed from each breast
• which results in a loss of 2 to 3 bra cup sizes
• Breast enlargement causes back pain

Ear surgery

• to correct protruding ears

Breast reconstruction of the affected breast

• mastectomy due to breast cancer
• that is, all the solutions for repairing

Physical injuries resulting from an accident 

• Injuries such as burns, bites, etc.

Pathological skin lesions (tumors)

Gynecomastia

• If the mammary gland is visible on a mammogram

Congenital malformations requiring reconstructive surgery

• cleft lips or cleft palates
• muscle atrophy, paraplegia, hemiplegia, sequelae of clubfoot

2. Procedures that may be covered upon request for prior authorization*

*(indirect coverage)

In such cases, the plastic surgeon will provide you with arequestfor prior approval that he or she has filled out.

Send it to your local health insurance office and wait for a response within 15 days.

A medical advisor will schedule an appointment with you andwill decide whether or not to approve your coverage, for example:

• Septoplasty (functionalrhinoplasty)
  • if the patient has a confirmed respiratory condition
  • These are mainly cases of birth defects
• Tummy tuck
  • when the abdominal wall is covered, with the pubis fully or partially covered
  • when there are hernias in the abdominal wall
• Breast augmentation with implants
  • in cases where the cup size is smaller than A or there is breast agenesis
  • the breasts are tubular (tube-shaped) 
  • or where the asymmetry is very pronounced, with a difference of at least one cup size

If you don't see your cosmetic surgery procedure on this list,

It is best to make an appointment with a plastic surgeon for an examination.

Only they can tell you whether coverage is automatic or requires a request to the CPAM or simply impossible.

This includes, for example, liposuction, breast and buttock fat grafting, facelifts, Botox or hyaluronic acid injections, lip augmentation, and Bichat balls

These are allpurely cosmetic procedures that are not covered by insurance.

Source: CCAM: Common Classification of Medical Procedures: visit the page onameli.fr