Understanding Health Insurance and Plastic Surgery

When it comes to using your health insurance for plastic surgery, there are generally two trains of thought. Some would like to believe that everything is a covered benefit (“I pay for my insurance, why wouldn’t it cover me?”) while others doubt their insurance would ever cover plastic surgery.  The truth is that plastic surgery falls into a confusing and hard to navigate middle area like no other healthcare specialty out there.  Because it covers both elective and medical surgeries, plastic surgery is often scrutinized by insurance companies leaving both patient and doctor to “prove” the need for surgery.

There are some issues that require plastic surgery, no questions asked.  Burns, wounds, facial fractures, lacerations and breast cancer generally fall into that category.  There are also procedures that are simply never covered by health insurance.  Facial fillers, skincare and breast augmentation are examples of elective procedures.  Then there are several common procedures that can be covered by insurance but only under certain circumstances.  Procedures such as breast reduction, skin removal, gender re-assignment and rhinoplasty (nose job) are examples that fall into this foggy area.

So, why is that? Well, the short answer is that these types of procedures are sometimes a personal choice while other times they are performed to relieve long-term medical issues to which there is no other option left except surgery.  What insurance companies have to determine is the answer to the age-old question, “is it a want or a need?”

When you see a plastic surgeon for a procedure that you believe is covered by your healthcare insurance, you and your surgeon have a burden of proof to meet.  Is the procedure a “medical necessity”?  Is your issue creating a medical problem?  Is your problem causing you pain or functional issues?  Is it stopping you from doing necessary day to day things? Have you tried to relieve your symptoms in any other way? Medications? Diet? Exercise? Other treatments?  Have you seen a doctor that diagnosed you with a medical condition?  These are the questions that will be asked, either of you or your surgeon.  Many insurance companies have a medical policy written with a specific criteria for coverage that must be met in order to qualify for coverage of certain procedures.  These policies are usually available to you online.

When hoping to obtain insurance coverage for a plastic surgery procedure, first ask yourself if your reasons for wanting surgery are medically necessary.  Second, be prepared to show why you believe so and in what ways you’ve investigated other solutions.  Next, understand your insurance’s criteria for coverage.  And, lastly, supporting documentationfrom other physicians is always helpful in making your case.

Partners in Plastic Surgery has experience navigating these tricky waters and is here to be an aid to you.  Contact Dr. Dennis Hammond and Dr. Andrea Van Pelt’s billing team if you have further questions about healthcare coverage and plastic surgery.