Policies must cover at least 10 essential health benefits, but unfortunately, cosmetic surgery is not among them. Insurance will cover the cost of some procedures if they are considered reconstructive in nature (rather than purely cosmetic). Breast augmentation, also known as breast surgery, may be covered by insurance under certain circumstances. When talking about plastic surgery covered by insurance, the question always boils down to what is “aesthetic” versus “reconstructive”.
Aging is normal, so if someone comes to work on their breasts due to the normal aging process, we consider that the cosmetic, according to Dr. Johnson. But the notion of what is “normal” and what is a “deformity” is constantly evolving. This includes reviewing previous reconstructions, says Dr.
Maria LoTempio, a plastic surgeon based in New York City who specializes in reconstructive and cosmetic surgery exclusively for women. This means that after an initial reconstruction, a woman can opt for a different reconstructive approach in order to improve the aesthetic result. LoTempio notes that the likelihood of insurance coverage decreases as time passes after the initial reconstruction, although in one case, one patient received full coverage for a significant review nearly eight years after her initial surgery. Johnson suggests that patients read their plans carefully and work closely with the insurance company's customer service representatives to determine if the desired surgery will be covered.
In addition to breast reconstruction, breast implant revision surgery may also be covered by insurance, according to the American Society of Plastic Surgeons (ASPS). Johnson points out that women who have already had a “breast operation” can receive insurance payment for the removal of their implants if a doctor determines that the implants are defective. On the other hand, there is breast reduction surgery, a procedure in which the surgeon removes adipose tissue, glandular tissue and excess skin. Beyond Aesthetics, Women Can Choose Breast Reduction to Address Discomfort.
ASPS says many insurance companies cover this surgery. Johnson notes that insurance companies tend to use cup size as a guideline (often denying coverage if you're not a “DD” or larger). Johnson recommends documenting symptoms and their duration as well as all non-surgical measures taken by the woman that have failed (such as diet, exercise, supportive bras, chiropractic, and massage). It's also a good idea to document a woman's willingness to endure scars in order to ease her symptoms, as this shows that his desire for surgery is not frivolous.
Johnson adds that insurance companies are more willing to pay for surgery on teens and young adults than older adults. There is a common belief that “if this guy survived adolescence and early twenties without surgery, that's fine” he says. After significant weight loss, some people may be left with excess skin. Patients may choose to undergo a paniculectomy, a surgical procedure to remove excess skin and fat hanging from the abdomen.
In terms of insurance coverage, the law continues to evolve in this area according to Dr. Then they decided it was their own problem and began to deny coverage he recalls. If you've never heard of a paniculectomy, it's likely that these unusual cosmetic surgeries are also new to you. While a paniculectomy only removes excess skin, a tummy tuck (also known as abdominoplasty) involves removing excess skin and fat from the abdomen and tightening the fascia found in the abdominal muscles according to Mayo Clinic.
However, a tummy tuck will be covered by insurance when done as part of a breast reconstruction. For example, in what is known as the DIEP Flap procedure Dr. LoTempio uses the skin and adipose tissue in the abdomen to replace the skin and tissue removed from the breast during mastectomy resulting in a soft natural and reconstructed breast. SIEA flap surgery uses blood vessels in the lower abdomen just below the skin.
Is a cosmetic procedure ever covered by insurance? That's not to say there are no exceptions to the rule. While elective procedures that are purely cosmetic in nature will always operate (pun intended) outside the purview of insurance companies plastic surgery procedures that can be classified as “medically necessary” are often part of insurance policies. So what makes an invasive or non-invasive procedure medically necessary and therefore covered by a health insurance plan? The AEDITION breaks it down. In June 1989 the American Medical Association (AMA) adopted definitions of “cosmetic surgery” and “reconstructive surgery” used by health insurance companies to determine coverage.
While exact standards may vary by insurance company ASPS offers recommended criteria for distinguishing between a cosmetic surgery procedure and plastic or reconstructive surgery that providers can use when explaining treatments that have a dual aesthetic and functional purpose. Aging eyelids not only cause cosmetic problems drooping eyelids have the ability to impair vision. For patients suffering from vision problems as a result of sagging skin around the eyes an upper eyelid blepharoplasty may be considered medically necessary to correct the problem during which a plastic or oculoplastic surgeon will remove excess skin to lift and open the eye. While many insurance policies will cover the functional component of surgery they may also consider medically necessary procedures such as paniculectomy or tummy tuck if they are causing pain or discomfort or putting patients at risk of developing skin conditions.
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