With plastic surgery becoming more mainstream in our society, patients often wonder how much of the procedure their health insurance will cover. For the most part, major insurance companies do not cover cosmetic procedures, unless it is deemed medically necessary, such as reconstructive plastic surgery. It varies from one insurance company to another, but a person who is electing to have a breast augmentation to increase the size of her breasts would not be covered, however, a woman having the procedure following a mastectomy would be covered.
The definition of cosmetic surgery varies, though from an insurance perspective, cosmetic surgery refers to any surgery with the purpose to modify or improve the appearance of a physical feature with no specific medical reason to do so. A medical need could include a condition that causes significant physical dysfunction or psychological distress to a patient, but many health insurance companies have defined criteria to determine if the surgery meets the requirements for coverage.
When Health Insurance May Cover Cosmetic Procedures
It’s not all bad news though, as there are some procedures that commonly are fully or partially covered by health insurance. In regards to nose jobs, insurance tends to cover septoplasty for patients with a deviated septum who experience disruptive breathing. Septoplasty surgery involves the straightening of your nasal septum and repositioning it to the middle of your nose. Aesthetic changes to the nose (rhinoplasty) are not covered by insurance, but to save on out of pocket expenses, many patients undergo both procedures simultaneously. The surgeon bills the insurance company for the septoplasty, and the cosmetic portion is billed directly to the patient.
Breast reduction, also called reduction mammoplasty, is often covered by insurance, but getting approved may be difficult. Insurance companies want to see that a patient has first tried nonsurgical means, such as physical therapy and/or chiropractic treatments, to resolve issues such as neck, back, and/or shoulder pain. If problems still persist, it helps for a patient to have several doctor recommendations, such as from a primary-care doctor, gynecologist, plastic surgeon, and chiropractor to have breast reduction surgery. A substantial amount of tissue, about a pound in weight or 400-500cc, needs to be taken from each breast in order for health insurance carriers to deem the surgery necessary.
Upper eyelid surgery, known as blepharoplasty, removes excess skin, muscle, and sometimes fat from the upper eyelid. This procedure may be covered by insurance when the surgery is performed to eliminate the redundant skin that is interfering with a patient’s sight. In addition to a clinical exam, insurance companies may request a photo of the patient’s eyelid droop, known as dermatochlasia (excess skin above the eyelid), and request a Visual Field Test to be performed by an ophthalmologist to show that eyelid surgery would improve the patient’s vision.
When it comes to plastic surgery, one of the most surprising aspects of health insurance is that carriers will pay for obese patients to have gastric bypass surgery, but often plastic surgery to remove excess skin as a direct result of that weight loss is considered cosmetic in nature, and therefore not covered by insurance companies. Insurance may cover surgery for patients who suffer from chronic ulcers or rashes, that cannot be treated with creams, or who have excess skin that completely covers the pubic region.
Cosmetic procedures done through insurance often require the surgery to be done at a hospital, or outpatient surgery center that also accepts your health insurance carrier. Health coverage for the procedures listed above vary greatly among health insurance carriers, so it is important to speak with your carrier prior to surgery to ensure what is and what is not covered.
For patients in which health insurance is not an option, most plastic surgeons offer financing for their patients, making the procedures affordable even without insurance assistance. If you have any questions or feedback, please leave them in the comments below or email Dr. Azad at DrAzad@KamranAzadMD.com.
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