Health insurance for plastic surgery coverage and costs explained

Plastic surgery is often perceived as a luxury, with many assuming that it falls entirely outside the scope of health insurance. While this is true for most cosmetic procedures, there are cases where health insurance can cover plastic surgery—particularly when it is deemed medically necessary.

This guide will walk you through the basics of how health insurance interacts with plastic surgery, the types of procedures that may qualify for coverage, and how you can navigate the complex world of insurance claims for surgical procedures.

Topic	Key Points
Types of Plastic Surgery	– Cosmetic Surgery: Not typically covered by insurance. – Reconstructive Surgery: Often covered if deemed medically necessary.
Medically Necessary Procedures	– Insurance covers surgeries like breast reconstruction, cleft lip repair, and rhinoplasty for breathing issues.
Out-of-Pocket Costs	– Cosmetic surgery costs: $3,500 – $12,000 depending on the procedure.
Financing Options	– Payment plans, medical credit cards, and third-party lenders.
Steps for Insurance Coverage	– Confirm with insurance provider. – Get pre-authorization. – Appeal denied claims if necessary.
Supplemental Options	– Supplemental insurance plans. – Medical tourism (cost savings, but risks involved).

What Is Plastic Surgery?

Plastic surgery is a medical specialty that focuses on the repair, reconstruction, or alteration of the human body. It is divided into two primary categories:

1. Cosmetic Surgery: These are elective procedures designed to enhance appearance. Examples include facelifts, liposuction, and breast augmentations. Health insurance typically does not cover cosmetic surgeries.
2. Reconstructive Surgery: These procedures aim to correct deformities caused by accidents, medical conditions, or congenital disabilities. Surgeries like breast reconstruction after a mastectomy, cleft lip repair, and skin grafting after burns are some examples. Reconstructive surgeries are often covered by health insurance because they improve a person’s function or quality of life.

Types of Plastic Surgery Covered by Health Insurance

When discussing health insurance coverage for plastic surgery, the distinction between cosmetic and reconstructive surgery is crucial. Insurance companies tend to cover procedures that are considered medically necessary. But how is medical necessity defined?

Medical Necessity: The Key to Insurance Coverage

Health insurance providers typically cover reconstructive surgeries if they are needed to restore normal function, relieve pain, or correct defects that affect a person’s quality of life. The term medical necessity is the deciding factor for whether a procedure will be covered.

Some examples of plastic surgeries that are often covered by insurance when deemed medically necessary include:

• Breast reconstruction after mastectomy.
• Rhinoplasty to correct breathing problems due to a deviated septum.
• Eyelid surgery (blepharoplasty) if drooping eyelids impair vision.
• Skin grafting following severe burns.

However, for insurance to approve coverage, the patient must provide medical documentation that demonstrates the need for the surgery. This may include tests, doctor’s notes, and other forms of evidence showing that the procedure is not purely cosmetic.

Common Reconstructive Procedures Covered by Insurance

Let’s take a closer look at some of the reconstructive surgeries typically covered by insurance:

• Breast Reconstruction: Women who have undergone mastectomies as part of breast cancer treatment are entitled to breast reconstruction coverage under the Women’s Health and Cancer Rights Act (WHCRA). This law mandates that health insurance companies cover breast reconstruction surgeries, including nipple reconstruction and symmetry procedures for the other breast.
• Cleft Lip and Palate Surgery: Children born with cleft lips or palates often require multiple surgeries to correct their appearance and improve their ability to speak and eat. These surgeries are generally covered by insurance due to the impact on the child’s health and development.
• Deviated Septum Correction: While rhinoplasty for cosmetic reasons is rarely covered by insurance, a deviated septum that impairs breathing may qualify as medically necessary. In these cases, insurance will typically cover the part of the surgery related to correcting the septum, but not necessarily any cosmetic modifications.

When Plastic Surgery Costs Fall on You

In many cases, patients must bear the costs of plastic surgery themselves, especially for elective cosmetic procedures that are not considered medically necessary. Understanding the potential costs involved can help you make informed decisions if your surgery isn’t covered by insurance.

Out-of-Pocket Costs for Common Cosmetic Procedures

Cosmetic surgeries are typically paid out-of-pocket by the patient, as insurance companies view these procedures as elective, and they do not address medical or functional concerns. The costs for cosmetic surgeries can vary widely based on the complexity of the procedure, the surgeon’s expertise, and the location of the practice. Here are some average costs of popular cosmetic surgeries:

• Breast Augmentation: $6,000 – $8,000
• Liposuction: $3,500 – $7,000
• Facelift: $7,000 – $12,000
• Tummy Tuck (Abdominoplasty): $6,000 – $10,000

These prices often do not include additional costs like anesthesia, operating room fees, and post-surgery medications, which can add up quickly.

Financing Options for Cosmetic Surgery

If you’re considering a cosmetic surgery that isn’t covered by insurance, there are several financing options to help make the costs more manageable:

• Payment Plans: Many plastic surgeons offer in-house financing options or partner with third-party lenders to provide installment payment plans. These allow you to spread the cost of your surgery over several months or years.
• Medical Credit Cards: Some companies offer credit cards specifically designed for medical expenses. These cards often come with promotional 0% interest rates for a set period, making it easier to pay for your surgery without incurring high-interest charges.

Navigating Health Insurance for Plastic Surgery

If your surgery may qualify for insurance coverage, understanding the process can be challenging. Here are some steps to help you navigate insurance claims for plastic surgery:

Confirm Coverage with Your Insurance Provider

Before scheduling any surgery, it’s essential to contact your health insurance provider to verify coverage. When speaking with an insurance representative, ask the following questions:

• Is this procedure covered under my plan?
• What documentation do I need to submit for approval?
• Does the procedure require pre-authorization?

It’s also helpful to get any approvals or denials from the insurance company in writing, so you have a clear record of their decision.

Appealing a Denied Claim

If your insurance company denies coverage for a procedure that you believe is medically necessary, you have the right to appeal their decision. The appeals process can be time-consuming, but it’s worth pursuing if you believe the surgery is essential for your health and well-being. To strengthen your appeal, consider getting a second opinion from another physician who can support your claim.

Supplemental Insurance and Medical Tourism

If traditional health insurance doesn’t cover the plastic surgery you need, there are alternative ways to manage the costs.

Supplemental Insurance for Elective Procedures

Some companies offer specialized supplemental insurance plans that cover elective plastic surgery. These policies can help pay for cosmetic procedures not covered by traditional insurance, although premiums may be high.

Medical Tourism: Is It Worth the Risk?

Some patients choose to travel abroad for plastic surgery, as costs can be significantly lower in countries like Mexico, Thailand, or Brazil. While medical tourism can save money, it carries risks, including potential complications, lack of legal recourse, and differing medical standards. Before opting for surgery abroad, thoroughly research the credentials of the surgeon and facility, and ensure they meet international safety standards.

Conclusion

Navigating the world of health insurance and plastic surgery can be confusing, but understanding the difference between cosmetic and reconstructive procedures is key to determining coverage. While most cosmetic surgeries are not covered by insurance, medically necessary reconstructive procedures often are. Always consult both your plastic surgeon and your insurance provider before undergoing any surgery, and explore your options for financing if insurance won’t cover the cost. Planning ahead and being informed will help ensure that your experience is as smooth and stress-free as possible.

FAQs

1. Does health insurance cover cosmetic surgery?
No, health insurance typically does not cover cosmetic surgery since these procedures are considered elective and not medically necessary.

2. What types of plastic surgery are covered by insurance?
Reconstructive surgeries, such as breast reconstruction after a mastectomy, cleft lip repair, and surgeries to correct breathing issues, may be covered if deemed medically necessary.

3. How can I determine if my plastic surgery will be covered?
Contact your health insurance provider to verify coverage. Ask about pre-authorization and what documentation is required to prove medical necessity.

4. What should I do if my insurance claim for plastic surgery is denied?
You have the right to appeal a denied claim. Gather supporting documentation, potentially including a second opinion from another doctor, and follow your insurer’s appeal process.

5. Are there financing options available for cosmetic surgery?
Yes, many plastic surgeons offer payment plans, and there are medical credit cards and third-party lenders that can help finance cosmetic procedures.

6. What is medical necessity in relation to plastic surgery?
Medical necessity refers to procedures that are essential for improving a patient’s health or quality of life, which can qualify for insurance coverage.