Insurance Coverage and Cosmetic Surgery

First we must differentiate between cosmetic surgery and reconstructive surgery because purely cosmetic surgeries are almost never covered by insurance plans. However, there is a large gray area surrounding what can be considered reconstructive as opposed to plastic surgery. The AMA (American Medical Association) and the ASPS (American Society of Plastic Surgeons) have developed definitions for both terms to help alleviate confusion:


Reconstructive Surgery—is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.

Cosmetic Surgery-is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

The general rule encompassing insurance coverage of elective surgeries is that if there is a medical reason for the surgery, it will be covered under reconstructive surgery. This means that you suffer an injury, or are born with a malformation that can be traced to medical problems that require attention (i.e. restoring proper function or relieving pain and suffering) your insurance is likely to cover it.

Many insurance companies have medical criteria that must be met in order for them to cover the costs of surgery. This is especially prevalent in breast reduction cases. Depending on height, weight, and other miscellaneous medical conditions, a certain number of grams must be taken off each breast. The insurance company may also require photographs of the procedure/before and after pictures for their company records.

With most reconstructive surgeries, prior authorization by a physician is needed, and it is the physician's office that will help you contact the insurance company with your medical information. The insurance company will then determine what they are willing to cover. The final bill to you will depend upon that decision as well as the amount of copayment and deductible that is outlined in your contract. At this time you should be sure of your plan and what you will owe for the surgery. If you're confused, be sure to ask questions of both the insurance company and/or your physician until you fully understand what you will be responsible for.

If your request is ultimately denied by the insurance company, you can appeal the decision. This involves writing a letter to your insurer asking for a reconsideration, and have your surgeon do this as well. Make sure that the company outlines from their policy book why they have denied your procedure and ask another board certified plastic surgeon to review the case. It is also helpful to send a copy to your insurance commissioner. If the decision is reversed, inform your insurance commissioner. Always keep a record of all correspondence and calls made for your records.

If you do end up paying for the procedure yourself, you may be able to work out a payment plan with your physician. Since most physicians require payment at the time of or prior to surgery, you should discuss your options with the front office before committing to anything. The physician's office may also work with a financing company that can give you monthly payment options. It's best to meet with your physician first to determine what sort of procedure you need or desire and then decide, together, whether or not you think you'll be eligible for insurance coverage.

Below is a list of some cosmetic procedures that can also be considered reconstructive surgeries under certain circumstances:

ABDOMINAL SURGERY, WHEN IT IS PERFORMED TO:

• Alleviate health problems such as back pain, sores, hernia, rashes
  Restore the ability to walk normally