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What plastic surgery your insurance may cover?

Plastic surgery procedures are not something we think of us being covered by our health insurance providers, but there are times when insurance companies will pay out for plastic surgery if it can be shown there is a legitimate medical reason necessitating the surgery.

Insurance providers generally see a distinction between purely cosmetic surgery and reconstructive surgery, following the definitions provided by the American Society of Plastic Surgeons (ASPS) and the American Medical Association (AMA):

Cosmetic surgery is changing something about your appearance because you are unhappy with it – such as the shape of your nose, your breasts being too large or too much fat on your hips.

Reconstructive surgery is performed to improve the look and/or function of abnormalities caused by disease, trauma, congenital and developmental problems that affect everyday life, such as cleft lip and palate, or a mastectomy because of a tumor.

Generally, insurance providers will not provide cover for cosmetic surgery, but will for reconstructive surgery if there is a medical reason.

Legitimate Medical Reasons

These definitions may make things reasonably clear, but there are gray areas which ordinarily your insurance company may consider fall under the former category of purely cosmetic surgery, but if you can demonstrate it affects your everyday life then it could be considered a legitimate medical reason and may be covered under the latter.

This is where you will need your doctor and surgeon to provide supporting information for your claim, as the more evidence you have of it being a medical necessity then the greater likelihood of your insurance provider cover.

Some examples of ‘cosmetic surgery’ procedures that may be covered include:

Breast Reduction

Large breasts may cause other health issues including pain and discomfort in the back and neck, and in these circumstances breast reduction surgery may be seen as a medical necessity in order to alleviate other health problems.

Eyelid Surgery

Eyelid surgery, or blepharoplasty as it is also known, is typically used as a cosmetic procedure to remove drooping eyelids or eye bags on either the upper, lower or both eyes. However, it can be demonstrated that it is affecting your eyesight then it could be covered by your insurance provider.

Hand Surgery

Surgery for problems such as Dupuytren’s contracture, where nodules develop on the fingers causing them to bend toward the palm. The disease can be a nuisance, affecting dexterity as well as giving the hands an abnormal appearance, and can be corrected with surgery.

Nose Surgery

Nose surgery, or rhinoplasty as it is known medically, may be performed purely as a cosmetic procedure to improve the shape of a person’s nose that they are unhappy with. However, it can also be used to alleviate breathing problems caused by congenital defects, trauma or injury.

Weight loss Surgery

Morbidly obese patients may be able to claim for bariatric surgery to help with weight loss, although approval may only be given after a supervisory period of diet and exercise as well as a psychiatric evaluation.

How will you know if you can claim?

The simplest way to find out, of course, is to ask your insurance provider, but even if they say ‘no’, one survey revealed that about half the patients who appealed were successful in getting their claims paid, so it is worth being persistent.

Many patients have also found that it is easier to claim after you have had surgery rather than trying to get your insurer to agree beforehand – although this isn’t the ideal situation as you will have to pay the costs upfront, which you may never get the back.

The general rule for making a claim for plastic surgery from your insurance provider is to get as much supporting evidence as possible to back up your claim from your doctor and surgeon that it is a medical necessity – and if you can demonstrate the limitations the condition is having on your everyday life even better.

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