Medical Insurance Covers Cosmetic Surgery?

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, anaesthesia, and post-surgical devices. One common question perspective patients have when considering costs is whether their medical insurance plan will cover the procedure.


Your health insurance can cover the cost of a plastic surgery based on the conditions of your health insurance if the operation is considered reconstructive and not cosmetic.

Unfortunately, most health insurance companies do not cover cosmetic surgery as it is optional and generally not considered necessary to maintain the quality of life or function of the body.


Who bears the costs for cosmetic, reconstructive 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.

  • 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 patient’s’ appearance or self-esteem.

When does health insurance include cover for plastic surgery?

The cost of plastic surgery depends on your insurance company, the nature of your health insurance and the definition of the required procedure. To determine if the procedure is covered, it is important to know whether:

  • The surgery is cosmetic
  • Reconstructive
  • or essential to body function or preserving your quality of life

Answers to these questions are part of the process to determine if they are being addressed.

Although insurance policies may vary depending on what is considered covered, most insurance companies follow certain guidelines to determine what is considered reconstructive or necessary and what is considered cosmetic.

Nowadays, many insurance companies refuse cover because they consider circumcision a cosmetic product.
Because of these differences, it is very important to contact your insurer and discuss the classification of your case. While plastic surgeons (and their accountants) can advise you on the potential insurance cover potential, it is always wise to contact the source. If the insurance covers the desired procedure, you must arrange a consultation with your plastic surgeon to evaluate your case and establish a diagnosis and treatment plan.


In addition to this disclaimer, here are some procedures that your insurance may cover:

SEPTOPLASTY

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.

BREAST REDUCTION

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.

EYELID SURGERY

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.

EAR SURGERY

Otoplasty may be covered by your policy as long as the procedure is performed to correct deformed ears by birth, illness or injury.

FACIAL SURGERY

Facial disorders that are caused by paralysis, treat deformities of the facial muscles, the head or the neck.

HAND SURGERY

For operations to treat carpal tunnel syndrome, Dupuytren’s contracture, nerve damage, tendons, fused fingers or other deformities.

NOSE SURGERY

Performed to correct deformities due to birth, illness or breathing problems.


Also Read: Top 5 best life insurance plans in India


Examples of cosmetic surgeries that are not likely to be covered by health insurance

Unfortunately, most health insurance companies do not cover cosmetic surgery as it is optional and generally not considered necessary to maintain the quality of life or function of the body.

The following are examples of operations that are not routinely covered by health insurance, although exceptions may apply due to exceptional circumstances.

  • liposuction
  • breast augmentation
  • eyelid surgery


How do you ensure that your plastic surgery is covered by health insurance before you plan surgery?


  1. Contact your health insurance representative or insurance company directly to find out what coverage you have for plastic surgery.

    2. Get a detailed quote with a detailed cost estimate for your plastic surgery procedure so that you can compare it to covering your policy.

    3. Find out what your deductible would be in case of coverage.

    4. Find out how much you can pay the maximum and whether you expect to pay a percentage of the process.

    5. Find out which related medicines are treated like pain killers

    6. Determine if the insurance company can pay for part of your procedure by receiving half of the benefits and you can to half the cost of the procedure. Your doctor and specialists may be able to help you.

    7. Get the details of your coverage in writing so you will not be surprised. Never assume that something is insured unless your health insurance company confirms it.

In such situations, it is difficult to define the coverage of a health plan. Always check with your insurer before making any assumptions. It is difficult to determine what is considered necessary or simply cosmetic. In some cases, only certain parts of the operations can be covered, further complicating the matter. Be prepared before you try to apply for health insurance.

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FAQ’s


Q. Is the plastic/ cosmetic surgery health insured?

Answer: Your health insurance policy may pay for plastic surgery depending on the terms and conditions of your health insurance plan if the surgery is considered reconstructive and non-cosmetic.
Reconstructive surgery is considered medically necessary and covered by most health insurance companies. Nasal procedures, breast reduction and weight loss are treated if the goal is to relieve pain and discomfort. Some companies offer partial coverage of the medically necessary part of a procedure.


Q. What is the difference between a septoplasty and a rhinoplasty?

Answer: A rhinoplasty, or nose job, is an aesthetic/cosmetic plastic surgery to reshape or resize your nose.
A septoplasty, also known as a deviated septum, is a corrective surgical procedure designed to smooth the nasal septum, with the septum separating the two nasal cavities.


Q. Is plastic surgery and cosmetic surgery the same?

Answer: A considerable number of plastic surgeons focus on cosmetic surgery and therefore the terms are often used interchangeably. It is not technically correct. Cosmetic surgery and plastic surgery are closely related specialities, but they are not the same.


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