Does your insurance cover plastic surgery?

More than 16 million Americans received plastic surgery in 2006, according to the American Society of Plastic Surgeons (ASPS). Many of the procedures were performed on patients who elected the surgery hoping to improve physical attributes and self–esteem. Other patients received the surgery in response to the diagnosis of a medical condition or serious injury. It is in the determination of "medically necessary" wherein health insurance companies decide if and to what extent plastic surgery costs are covered.

Important: Remember that there are a variety of health insurance plans available. Information on the types of procedures that are covered or not covered, as well as steps which determine the level of medical necessity, can be found in your plan information or by contacting your provider. Your plan also should include information concerning an appeals process.

Medically Necessary
Most health insurance plans will cover plastic surgery to the extent it is medically necessary. Medically necessary procedures are often called "reconstructive." Other procedures that are not considered medically necessary are often called "elective" or "cosmetic."

Reconstructive Surgery
The American Medical Association (AMA) and the ASPS define reconstructive surgery as follows: "Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but also may be done to approximate a normal appearance."

Reconstructive surgery is generally covered by health insurance. Such procedures include skin grafting and facial reconstruction following an accident. It may also cover procedures resulting from a medical condition, such as eyelid surgery if drooping eyelids are obscuring a patient's vision.

It is important to review your health insurance plan and contact your provider for information concerning the extent of coverage. For example, your plan may cover the full cost of facial reconstructive surgery but only a portion of the cost of a certain type of anesthesia or prescription. Further, some plans limit the amount of time it will pay for hospitalization.

Elective or Cosmetic Surgery
The AMA and ASPS define cosmetic surgery as follows: "Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self–esteem."

Procedures considered "elective" or "cosmetic" by the health insurance provider are generally not covered by health insurance. Such procedures may include breast implants, face lifts, liposuction and abdominoplasty (removing excess skin around the abdomen).

In some cases, cosmetic surgery can be considered medically necessary. Examples include breast reconstruction after a mastectomy and nose surgery (rhinoplasty and/or septoplasty) if it will correct a defect that causes breathing difficulties. For more information on cosmetic procedures that may be covered due to medical necessity, review your health insurance plan and contact your provider.

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