We’ve all heard the rumors, typically pronounced with some authority:
“Military spouses can choose ONE plastic surgery covered by TRICARE.”
“I heard you can you get a boob job for body image issues, and the military will pay for it.”
Or some variation on the above.
That person knew someone who knew someone who had it done. Though I’m not sure where these stories originated, spouses may envision getting a free facelift, going in for LASIK surgery, or finally being approved for a tummy tuck to alleviate a saggy post-baby belly.
Well, slow down before you get too far down that road. To the question, “Does TRICARE cover elective surgeries?” the answer is as clear as are most things military related--it’s complicated. In fact, to answer the above question, TRICARE themselves say, “It depends.”
Let’s get the facts.
Does TRICARE cover reconstructive surgery?
Their answer: Yes, but only for birth defects, accidental injury, or surgical trauma.
Though not all inclusive, here’s a list of what IS covered:
“TRICARE covers cosmetic, reconstructive, and plastic surgery to improve the physical appearance of a beneficiary only under the following circumstances:
- Correction of a birth defect (includes cleft lip)
- Restoration of a body form following an accidental injury
- Revision of disfiguring and extensive scars resulting from neoplastic surgery (i.e., surgery that removes a tumor or cyst)
- Reconstructive breast surgery following a medically necessary mastectomy
- Reconstructive breast surgery due to a congenital anomaly (birth defect)
- Penile implants and testicular prostheses for conditions resulting from organic origins or for organic impotency
- Surgery to correct pectus excavatum [sunken breastbone]
- Liposuction when medically necessary
- Panniculectomy (tummy tuck) performed in conjunction with an abdominal or pelvic surgery when medical review determines that the procedure significantly contributes to the safe and effective correction or improvement of bodily function.”
Here’s TRICARE’s list of what’s NOT covered:
- Dental congenital anomalies
- Elective correction of minor skin blemishes and marks
- Breast augmentation
- Face lifts
- Reduction mammoplasties (breast reductions), except in the case of significant pain due to large breasts
- Blepharoplasty (removal of excess skin of the eyelid)
- Rhinoplasties (nose surgery)
- Chemical peeling for the treatment of facial wrinkles or acne scars
- Hair transplants
- Electrolysis
- Removal of tattoos
- Liposuction for body contouring.
There are some other exclusions. See the complete list here.
And here’s another caveat: “To be covered, surgeries must be performed no later than December 31st of the year following the accidental injury or surgical trauma, except in the case of postmastectomy reconstructive breast surgery or cases involving children who may require a growth period.”
“Medically necessary” can prove to be the ambiguous ground. For instance, tummy tucks can be approved if a doctor determines an issue causing an impediment to daily living (i.e. reasons like recurring rashes, infections, problems due to the weight of excess skin, etc.). Reduction mammoplasty can also be approved with documentation from a doctor. TRICARE has a specific list of requirements for cases when reduction mammoplasty is covered, including medical symptoms such as backache, neck pain, shoulder grooving, poor posture, or inability to participate in physical activity, which must be documented by a physician.
Weight loss surgery and skin removal surgery may also be approved when deemed medically necessary and after meeting specific requirements. Check TRICARE’s full policy on bariatric surgery.
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What about LASIK?
The short answer is no. This is not a procedure that TRICARE considers, you guessed it, medically necessary.
While it’s worth noting that some locations or teaching hospitals might cover the above surgeries on a case-by-case basis, this would be outside the norm and definitely not something to count on. (And let’s be honest, do you want to be a practice subject for LASIK or breast augmentation?)
Why doesn’t TRICARE cover elective surgery? Should it?
TRICARE falls in line with most major insurance plans in that it doesn’t cover elective surgery done for cosmetic reasons or matters of convenience. And while insurers will probably always have a difference of opinion from providers about what should be covered, it’s understandable that costs must be contained when dealing with millions of beneficiaries (The latest figures show 4.6 million beneficiaries of the TRICARE Prime plan alone.). Still, if you think you might be eligible for one of the above procedures, don’t guess. Communicate with your healthcare provider.
Even if you know someone who seems to be the exception to TRICARE’s rules, the ‘must be medically necessary’ is the sticking point. Continue to talk with your doctor about any symptoms you’re having and stay up to date with TRICARE’s ever-changing policies. Who knows? Maybe the powers that be will agree that your tummy tuck falls on the approved list at some point.
**This isn’t meant to be specific advice for anyone’s situation, so be sure and consult with your provider and Tricare!
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This article has been modified to meet updated editorial standards at Military Spouse, which may include the augmentation of material that reflects the expertise and experiences of our staff.
