Can it be Covered by Insurance?

By Dr. Valerie Ablaza
I have stopped being surprised by the plastic surgery procedures that patients think, or hope, are covered by health insurance. A recent patient thought it was reasonable for insurance to pay for a facelift, since dealing with a younger clientele is an integral part of her job. Another person felt that if insurance companies will cover breast reductions, they should also pay for flat-chested women to get breast implants to “feel more like women”. How about insurance paying for a tummy tuck as a reward for losing a large amount of weight with sheer will power? Yes, I have heard it all and more. These inquiries are most likely a combination of misinformation and hopefulness.

Just to clarify, plastic surgery encompasses both cosmetic and reconstructive surgery. Specifically, cosmetic surgery is performed electively to reshape normal structures of the body to improve one’s appearance and is usually not covered by health insurance. Procedures that are personal choices and not considered medically necessary include liposuction, breast augmentation, breast lifts, and facelifts, to name a few.

Reconstructive surgery, on the other hand, is performed on abnormal body structures caused by congenital defects, trauma, infection, tumors or disease to improve function or restore a normal appearance. Reconstructive procedures are generally covered by most health insurance policies, although levels of coverage may vary greatly. That means, cleft lips and palates, facial lacerations, broken noses, absent breasts after mastectomy and oversized breasts causing neck and back pain are among the conditions that are reimbursed by insurance. But unfortunately, there are no guarantees.

People often say, “This procedure must be covered because I have great insurance and pay high premiums”. Even though certain procedures are typically covered by insurance, all decisions are made individually on a case-by-case basis. To make it more complicated, insurance policy terms can vary greatly so that some policies will cover many plastic surgery procedures while others are more limited in coverage. It’s also important to remember that in an office that does not participate with some or any insurance plans, even surgery that gets pre-certified will result in some type of balance for the patient.

When it comes to health insurance covering plastic surgery, there are several “gray areas” that require special consideration by carriers. What this means is that there are some procedures performed by plastic surgeons that are generally considered cosmetic in nature that are occasionally reimbursed by insurance, under extenuating circumstances and with proper documentation. For instance, heavy upper eyelids impairing peripheral vision can be corrected with an eyelid lift, or blepharoplasty. Tummy tucks performed in cases of severe or recurrent infection and ulceration from hanging skin along the abdominal wall may be covered by health insurance while “nose jobs” done to improve an obstructed airway can usually get paid by health insurance.

For the average patient who consults with a plastic surgeon, a good way to get an idea of whether the procedure is coverable by insurance, just ask the question: Is the main reason to have this surgery for relief of symptoms or for cosmetic improvement? If the answer is still not clear, there’s no harm in asking. The good news is, there are exceptions to every rule.

Dr. Valerie Ablaza is a partner and the vice president of The Plastic Surgery Group. She is board certified by the American Society of Plastic Surgeons, is a fellow of the American College of Surgeons, and is a member of the American Society of Plastic Surgeons. She co-authored Beauty in Balance: A Common Sense Approach to Cosmetic Surgery and Treatments and was a guest author of Fifty Things to Do When You Turn Fifty.

Further Reading

» Obsessed with Plastic Surgery
» Plastic Surgery for a Sagging Economy
» Plastic Surgery Vacations
» Teen Plastic Surgery
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