Does Medical Insurance Cover Plastic Surgery?
According to the 2015 Plastic Surgery Statistics Report published by the American Society of Plastic Surgeons, over 1.7 million cosmetic surgical procedures were performed in fiscal year 2015. That’s a lot of surgeries!
Cosmetic surgery can be very expensive (average cost of cosmetic surgery), with the total cost comprised of physician fees, surgical materials (like implants); operating room costs, anesthesia, and post-surgical devices. One common question prospective patients have when considering costs is whether their medical insurance plan will cover the procedure.
Medical Insurance and Plastic Surgery
In general, each specific insurance company determines what procedures they will or will not cover. The biggest factor insurance companies consider is whether the procedure is reconstructive or cosmetic in nature. To this end many insurers use definitions provided by the American Medical Association (AMA) as follows:
- Reconstructive surgery refers to procedures performed to correct trauma, developmental defects, infection, or disease. Reconstructive procedures focus on improving function or normalizing appearance of the patient.
- Cosmetic surgery refers to procedures that are focused on improving the aesthetic appearance of the face or body to improve a patients’ appearance or self-esteem.
Many insurance companies, however, can interpret the above definitions differently depending on the specific procedure and situation. For example, the circumcision of boys was universally covered by insurance companies a decade ago. Today, more and more insurance companies are declining coverage as they consider circumcision to be cosmetic.
Due to these variances it is very important to contact your insurance provider and discuss how your procedure will be classified. While plastic surgeons (and their billing representatives) can counsel you on the potential for insurance coverage it’s always best to go to the source. If insurance will cover the procedure you want, you will have to schedule a consultation with your plastic surgeon to evaluate your case and provide a diagnosis and treatment plan.
With that disclaimer aside, here are some procedures that your insurance may cover:
Some insurance providers will cover septoplasty for patients who have a deviated septum that is disrupting their breathing. Many times your surgeon can also complete a rhinoplasty procedure at the same time as your septoplasty. While these two procedures are billed separately (medical insurance will only cover the septoplasty portion), many patients realize significant savings as portions of the surgeons fees and operating room costs are assumed by the insurance company.
Many insurers will cover breast reduction as long as the patient has a long documented history of back, neck, or shoulder pain that is not reduced after periods of physical therapy. However, many insurance companies require at least a pound of tissue to be removed from each breast in order for the procedure to be covered. For men, gynecomastia surgery may also be covered but it has a different set of guidelines than breast reduction for women.
Blepharoplasty procedures may be covered by your insurance if the droopy skin around the eyelids is causing vision related issues. Typically a field of vision exam or other tests will have to be done to prove a patient’s vision will improve from the procedure.
Otoplasty may be covered by your policy as long as the procedure is done to correct ears deformed through disease, injury, or birth.
Finally, you will need to contact your insurance company to make sure your chosen plastic surgeon is an in-network provider.