Does Insurance Cover Any Type of Plastic Surgery?

Plastic surgery is no longer just for the rich and famous.  Over the years, plastic surgery has become more popular.  Data from the American Society of Plastic surgeons found that nearly a quarter-million more cosmetic procedures were performed in 2018 compared to 2017. This trend is in line with the steady rise of plastic surgery performed in the prior 5 years. 

The most popular plastic surgery procedures include breast augmentation, liposuction, nose reshaping, eyelid surgery, and tummy tuck

Perhaps due to the increase in social media and an increase in selfies, plastic surgery has not only become more socially accepted, it is now something that people openly share about. 

Time has shifted from when plastic surgery was discrete, to now commonly seeing social media posts of post-operative bandaged selfies showing off their recovery process.  Plastic surgery not only improves a person’s aesthetic, but it also may lead to increased confidence, improving quality of life, so it’s a curious thought considering if insurance would cover something so generally beneficial.  

Paying for Plastic Surgery

Perhaps you have made the decision to pursue plastic surgery, or maybe just considering it.  A common question for many is, how will I pay for it?  While a lot of people consider getting plastic surgery, a big distractor is the cost.  

Plastic surgery procedures can be pricey, as well as associated costs aside from the surgery itself.  Additional costs include time-off of work, potentially paid care for children while you are recovering,  travel time, and potential hotel-costs or recovery center costs just to name a few. Americans spent more than $16.5 billion on cosmetic procedures in 2018, with most patients paying out of pocket.

Where Does Insurance Fit In?

So what about insurance? In the United States, insurance is expensive. First, you have monthly insurance premiums, then deductible, then co-pays.  All these charges add up.  The most disappointing thing is after spending so much money on insurance, when you consider treatment, you may discover that it is not covered.

Is Anything Covered?

It can often be heard that plastic surgery is not covered by insurance.  Insurance policies can be extremely difficult to understand and truly vary from policy to policy.  Also, the policy can change from year to year, altering the inclusion and exclusion criteria.  The good news is that some plastic surgeries ARE typically covered, regardless of your plan. 

Plastic surgery procedures classified as “medically necessary” are often covered by insurance policies.  What is included by the term, “medically necessary?”  Well, according to the American Medical Association (AMA), one of two categories apply:

  • Cosmetic surgery: performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem
  • Reconstructive surgery: Performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.

Based on these definitions, reconstructive surgery falls under being medically necessary, where cosmetic surgery does not.  

However, if the cosmetic procedure also treats a functional health problem in addition to an aesthetic issue, then it may be termed necessary.  If the medical provider (surgeon) is able to document the procedure as medically necessary, then it may be covered by insurance. This typically requires visual documentation of the concerns as well as documentation that non-surgical treatments have been unsuccessful in achieving desired results.

There is a fine line between what is considered medically necessary and what is not.  What is considered as cosmetic surgery versus medically necessary is entirely up to the insurance company who holds the policy. 

Here are some procedures that may be covered:

  • Weight-loss or bariatric surgery has been shown to decrease a patient’s risk of developing disorders such as diabetes, high blood pressure, and heart disease. There is also an associated decreased risk of mortality.  For these reasons, weight loss surgery is commonly approved by health insurance plans.  
  • Abdominal surgery that helps reduce significant amounts of hanging lower abdominal skin or an abdominal hernia may be covered. Two types of surgery that can achieve this include:
    • Abdominoplasty:  Repair of a hernia can be done through this lower abdominal incision. 
    • Panniculectomy.  The pannus is excess tissue of the lower abdomen below the belly button. A panniculectomy is when the pannus is surgically removed.
  • Blepharoplasty is the name for the surgical procedure that repairs droopy eyelids and may and possibly surround eye structures such as skin, muscle, and fat. Because this often impairs vision, this is typically covered by insurance companies.
  • If a facial surgery is performed to manage paralysis, or treat muscle deformities, it will likely be covered by healthcare insurance.
  • In some situations, Botox may be covered. Botox is the injection of Botulinum; Botox was FDA approved to treat chronic migraines in patients over the age of 18.
  • Post-Mastectomy Breast Reconstruction. Since the 1998 Women’s Health and Cancer Rights Act (WHCRA), health plans that cover mastectomy, must also cover breast reconstruction.
  • Breast reduction in females and well as males may be approved if, for example, it is causing significant back pain.
  • Otoplasty (ear surgery) is a surgical procedure that corrects the outer ear. In conditions where there is a severe congenital deformity insurance may cover this type of procedure. This may affect hearing, and therefore may be considered medically necessary and covered by health insurance companies.
  • Septoplasty  is the surgical name for the procedure that corrects the nasal airway passages to improve your breathing.  This condition needs to be documented with both an exam and diagnostic studies.  This does not generally change the shape of your nose.   

Dr. Robert Applebaum

When choosing a surgeon for either cosmetic or reconstructive surgery, it is important to select a surgeon who is experienced in the type of procedure that you are considering. 

Dr. Robert Applebaum has over 25 years of experience in the field, and his staff are also very experienced in dealing with insurance. They can help you determine if the procedure you are considering will be covered by insurance, providing an inviting atmosphere right from the start.  

Another thing to consider is alternative financing options. Ask Dr. Applebaum about various financing options that he can recommend.

So, how do you know what procedures are covered?

Since every insurance policy is unique, the best way to know for sure is to check with your insurance and talk to your surgeon. Do not automatically assume a procedure is not covered before talking to your surgeon, even if your insurance company initially tells you it is not!

To Sum It Up

The plastic surgery you are considering may be more financially feasible than you initially think! 

In addition to cost, there are a lot of other important things to consider and discuss with your surgeon. There may be things your surgeon will recommend you focus on for weeks or months prior to surgery, for example quitting smoking.  Starting the process sooner than later will give you adequate time to ask appropriate questions and address any concerns that you may have, so schedule your complimentary consultation with Dr. Applebaum today!

Sources:

https://aedit.com/aedition/insurance-coverage-for-plastic-surgery-cosmetic-procedures

https://www.healthline.com/health-news/more-people-getting-plastic-surgery

https://www.plasticsurgery.org/for-medical-professionals/health-policy/recommended-insurance-coverage-criteria

https://www.thebalance.com/plastic-surgery-costs-and-what-insurance-may-cover-2645384

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