Before you go under the knife: will your insurance pay for your procedure?
Plastic surgery is either cosmetic or reconstructive. Health insurance policies usually don’t cover cosmetic plastic surgery: it’s not considered medically necessary. Reconstructive surgery is usually covered by insurance policies but levels of coverage vary among providers and policies, according to the American Society of Plastic Surgeons (ASPS).
Cosmetic versus Reconstructive Surgery
A nose job may be cosmetic and reconstructive if it corrects breathing.
Cosmetic surgery is meant to give new shape to normal body parts in order to improve appearance, confidence and self-esteem according to ASPS.
Reconstructive surgery is performed to improve appearance and function on abnormal body parts. Reasons for reconstructive surgery include trauma from an accident; disfigurement due to tumors, infection or disease; and defects of birth or development.
Gray Areas of Coverage
Mental health is a hard case to back up in terms of cosmetic surgery coverage.
Gray areas refer to plastic surgery that can be considered cosmetic and reconstructive. Having eyelid surgery may improve appearance and improve vision; nose surgery could correct breathing difficulties; a breast reduction might resolve back pain; or a tummy tuck could lower heart disease risk for an obese patient.
Medical documentation is required for an insurance company to consider whether to cover plastic surgery, to decide if there are valid medical reasons to have the surgery.
A plastic surgeon follows a code of ethics, according to the ASPS, and won’t try to misrepresent a cosmetic surgery as a medically necessary one.
The Fine Print
A drooping eyelid might be uncomfortable but surgery still isn't medically necessary.
Plastic surgeon Frank Meronk, Jr. says that it isn’t easy to get gray areas covered today. Even though a line of fine print in your insurance policy may talk about coverage of surgery meant to rectify "significant changes that impact on vision of the health of the eyes," this doesn’t mean your eyelid surgery will be covered.
The obscuring of vision must be severe and vision tests are looked at with a fine tooth comb, according to Dr. Meronk. Even if you do manage to qualify for coverage, your insurance company will likely only cover the minimum amount of surgery to correct the problem. That won’t be enough to improve appearance in the way a cosmetic procedure would, and few plastic surgeons are willing to forgo full payment.
Apply for Coverage
Your doctor can help you determine what will be covered by insurance.
Your doctor will send a preauthorization letter to your insurance company, detailing the procedure, the diagnosis and the fees. Your insurance company will review your case and base coverage on what portion (if any) of the procedure is medically necessary. The company then will reply with authorization for the procedure based on what is covered through your health plan. You don’t need permission; you can still go ahead with everything as long as you realize what costs you are responsible for.
Appealing Decisions
Look over your insurance policy carefully.
You can appeal the decision about coverage made by your insurance company. First read your policy carefully. If there is a specific statement in your plan that excludes the type of care you’re fighting for; you won’t get very far in your appeal.
The ASPS recommends writing a letter to the claims supervisor who signed the denial notification and explaining why coverage was denied and why you think the procedure should be covered. Ask for your request to be reviewed by an ASPS-certified plastic surgeon and ask for a copy of the specific statement in your policy that explains why coverage was denied.
Attach all of the paperwork: you doctor’s preauthorization letter, the denial and a position paper from your doctor. An ASPS position letter explains the procedure and the reasons it is done.
Don’t settle for vague responses. You have a right to see specific policy language that explains why your coverage was denied and these restrictions must have been in place when you first began your policy.
Attach duplicates of your correspondence to a letter to the insurance commissioner in your home state.
Tags: insurance company, improve appearance, medically necessary, cosmetic reconstructive, coverage denied
