The cosmetic exclusion
Medicare does not cover surgery aimed at improving appearance. It does cover prompt repair of accidental injury and surgery to improve the function of a malformed body part.
Reconstructive or cosmetic decides who pays
Insurers pay for reconstruction after cancer, injury, or a malformation, and not for surgery aimed at appearance. The note, the photos, and the prior authorization have to show which one it is. Cosmetic self-pay work sits outside insurance billing altogether.
Book a demoWhat decides payment in plastic surgery
Coverage turns on purpose, so documentation does more work here than in most surgical specialties.
Breast reconstruction protections
Medicare covers breast reconstruction after a mastectomy for breast cancer. For group and individual plans that cover mastectomy, federal law requires coverage for every stage of reconstruction, symmetry surgery on the other breast, and prostheses.
Procedures that need prior authorization
Medicare usually requires prior authorization for blepharoplasty, rhinoplasty, panniculectomy, and some botulinum toxin injections, because these can be cosmetic. The request has to show the functional problem.
Splitting the work with your practice
Many plastic surgery practices run insurance-billed reconstruction and cash-pay aesthetics under one roof.
What your practice keeps
Surgeons document functional impairment, photographs, and the medical reason for each procedure. Your team keeps cosmetic quotes, deposits, and financing.
What Taiga takes on
For insurance-billed cases, Taiga drafts codes from notes for surgeon approval, checks eligibility, scrubs and submits claims, and works every denial and appeal. Statements for insured patient balances follow the same path.
What needs a decision
Mixed sessions, where a covered repair and a cosmetic procedure happen together, need a clear rule for splitting charges and collecting the patient's share.
Questions for a plastic surgery fit call
Bring de-identified examples of a breast reconstruction stage, an eyelid or nasal case that needed authorization, and a mixed session.
How much is insurance-billed?
Estimate the share of your cases billed to insurance versus self-pay.
How are authorizations handled?
Explain who gathers photos and other proof of functional need, and who submits the requests.
How are mixed sessions priced?
Describe how you separate covered and cosmetic portions of one operation today.
For reconstructive-focused practices
Useful for an independent plastic surgery practice with meaningful reconstructive volume that wants insured claims and appeals handled by one team.
Where the line sits
Plastic and reconstructive surgery is not on Taiga's published specialty list, so bring your service mix and Taiga will tell you straight whether it fits. Purely cosmetic self-pay procedures are outside insurance billing and outside this page.
Questions about plastic surgery billing
Will Medicare pay for a blepharoplasty?
Only when it treats a functional problem rather than appearance, and Medicare usually requires prior authorization first. The record has to show the medical reason.
Do health plans have to cover reconstruction after mastectomy?
Medicare covers it after a mastectomy for breast cancer. Under federal law, group and individual plans that cover mastectomy must also cover reconstruction, symmetry surgery on the other breast, prostheses, and treatment of complications.
Can part of a combined cosmetic and reconstructive case go to insurance?
Only the medically necessary portion can be billed to insurance, and the patient pays for the cosmetic part. Clear notes and separate pricing keep that split defensible.
Do we have to change our EHR?
No. Taiga works alongside the EHR you already use, and your surgeons approve every code before it is submitted.
Bring your reconstructive case mix
Show Taiga your insured cases, authorization workload, and denial reasons. If it fits, onboarding takes about two weeks to first claim.
System guides show possible billing handoffs, not proven specialty compatibility.