There are millions of plastic surgeries done every year, and most of them are cosmetic and not covered by insurance. But did you know that your health insurance policy may cover some plastic surgeries?
Whether insurance covers a procedure depends on if the insurer considers it reconstructive or medically necessary.
Definitions That Determine If A Plastic Surgery Procedure Is Covered Or Not
Most health insurance companies adhere to the definitions given by the American Medical Association (AMA) or ASPS to determine the difference between cosmetic surgery, reconstructive surgery, and what is medically necessary:
- Reconstructive usually refers to a procedure on abnormal parts of the body caused by congenital issues, trauma, cancer, disease, or infection. This category includes procedures to enhance function or to provide a normal appearance.
- Cosmetic surgery includes both surgical and non-surgical procedures that enhance part of the body to improve confidence and appearance.
The Difference Between Medically Necessary and Cosmetic
What is considered medically necessary and cosmetic surgery depends on the insurance company, and it can change over the years. Factors include:
- The type of health insurance
- Research and how it is connected to the needs of patients
- Evolution of cosmetic procedures and medical treatments
Types Of Plastic Surgery Procedures That May Be Covered By Insurance
Below are some of the procedures listed on the ASPS website that your insurance policy may cover. Please check with your insurance provider to determine if it will cover a procedure you are considering:
- Ear surgery: If it is done to correct ears that were deformed at birth by injury or disease.
- Breast surgery: If it is done to reduce the size of the breasts, correct asymmetry, for reconstruction, or reduce male breasts.
- Abdominal surgery: If the procedure is done to improve health issues such as sores, hernia, back pain, or to improve the ability to walk.
- Eyelid surgery: If it is done to improve drooping eyelids that cause vision problems or correct eyelids positioned abnormally.
- Hand surgery: If it is done to fix carpal tunnel syndrome, nerve injuries, tendon injuries, fused fingers, or other related deformities.
- Nasal surgery: If the procedure is done to correct congenital issues, problems with breathing, or disease.
- Facial surgery: If it is done to balance one’s appearance caused by paralysis or to improve deformities in the facial muscles.
If you think you need a procedure that falls into any of the above categories, please talk to your surgeon about it. Your doctor can give his or her opinion if the condition may be reconstructive. Then, both of you can speak to your insurance company about it.
Cosmetic Surgery Procedures That Usually Are Not Covered
According to the ASPS, in the last 20 years, the number of plastic surgery procedures done for women increased 540% and 325% for men. So it makes sense that people who want cosmetic procedures may want to see if their health insurance policy will cover it.
But most elective procedures are not covered by health insurance policies because they are optional. Also, most procedures are not considered medically necessary to maintain one’s quality of life.
Some procedures that are not usually covered include:
However, there are some exceptions in extraordinary circumstances where the above procedures might be covered.
For example, while liposuction and tummy tucks are rarely are considered cosmetic, if a person is morbidly obese and has psychiatric conditions that the extra weight has caused, insurance might cover it.
However, this is usually only considered by insurance if the person has had a long-term evaluation of the condition, combined with a doctor-supervised weight program to attempt to address the problem with other methods.
Also, weight loss surgery is usually not covered and requires an exceptional situation to be an exception.
Example Of Other Plastic Surgery Procedures That May Be Covered
Nose jobs, or rhinoplasty, are usually considered cosmetic procedures. However, if a person has a lot of trouble breathing through the nose, insurance may cover it.
Also, the person may have trouble sleeping from the breathing issue, which could stem from a deviated septum. However, if the doctor can show the surgery is medically necessary and needed to live an everyday life, it may be covered.
Another procedure that may be covered in limited situations is breast surgery. If a person has excessively large breasts that cause discomfort and limits her ability to exercise, there could be an exception. Women in this situation can have severe shoulder and back pain that affects their quality of life.
If you think that your breast surgery could be medically necessary, you will need to submit forms and additional information from your doctor to the health insurance company. Depending on the insurer, they may want you to have physical therapy, lose weight, and attempt alternatives before considering covering it.
How To See If Your Plastic Surgery Procedure Is Covered
Before you set up a procedure, it’s wise to check with your health insurance to see if the procedure is covered:
- Talk to your insurance administrator to learn about the coverage you have for plastic surgery.
- Obtain an accurate estimate of the procedure you want from your surgeon so you can compare it with your insurance coverage.
- Ask what your deductible is if the surgery may be covered.
- Ask what the maximum amount is that the insurance policy may pay.
- Determine what medications, such as painkillers, could be covered.
- See if the insurance company may pay for part of the plastic surgery, such as for half of the medical costs, while you would pay for half of the cosmetic.
- Get all details about what may be covered or not in writing, so there are no surprises.
Request a Houston Plastic Surgery Consultation
Interested in a plastic surgery procedure in Houston? Please set up a consultation with Dr. Ashley Steinberg today. She’ll talk to you about the benefits and risks of the procedure to determine if you’re a good candidate for a plastic surgery procedure.
Does Insurance Cover Plastic Surgery? (2020). Accessed at https://www.verywellhealth.com/will-insurance-cover-the-cost-of-my-plastic-surgery-2710197
Plastic Surgery Costs And What Insurance May Cover. (2020). Accessed at https://www.thebalance.com/plastic-surgery-costs-and-what-insurance-may-cover-2645384