General information about health insurance coverage
This information has been provided to assist you in better understanding health
insurance benefits for plastic surgery. It is intended to answer a few basic
questions. It won't answer all of your questions, because a lot depends on individual
circumstances and your own insurance. Be sure to contact your insurance company
or your employer's Human Resources/Benefits department with any questions you
have about coverage for specific services.
What's covered
Your insurance policy is an agreement between you and your insurance company.
In contrast, an agreement on services and fees is an agreement between you
and your facial plastic surgeon. When you have surgery, you become responsible
for payment of the doctor's fees. Coverage for services and levels of payment
by your insurance company depend on the terms of the contract between you and
your insurance company. You are responsible for any amounts not covered by
your plan.
Reconstructive surgery is generally covered by most health insurance policies,
although coverage for specific procedures and levels of coverage may vary greatly.
Cosmetic surgery, however, is usually not covered by health insurance because
it is elective. Cosmetic surgery is your choice and not considered a medical
necessity.
There are a number of "gray areas" in coverage for plastic surgery
that sometimes require special consideration by an insurance carrier. These
areas usually involve surgical operations which may be reconstructive or cosmetic,
depending on each patient's situation. For example, eyelid surgery (blepharoplasty)
- a procedure normally performed to achieve cosmetic improvement - may be covered
if the eyelids are drooping severely and obscuring a patient's vision. Or,
nose surgery (rhinoplasty and/or septoplasty) may be covered if it will correct
a defect that causes breathing difficulties.
In assessing whether the procedure will be covered by the patient's insurance
contract, the carrier looks at the primary reason the procedure is being performed:
is it for relief of symptoms or for cosmetic improvement? If a procedure is
within these "gray areas," insurance companies often require prior
authorization or approval before the surgery is performed and/or extra documentation
after surgery to determine how much of the cost of your care they will cover.
