Health Insurance Plans for Cosmetic Surgery: Costly or Covered?

How many of us have stood at the checkout counter of the local mega mart, and perused the tabloids while waiting for our turn?  A staple of many a tabloid is the guessing game: which celebrity has had cosmetic surgery or perhaps some liposuction?  Yet, what about the lady at the front of the line, has she had costly surgery? 

The term “cosmetic surgery” encompasses a wide variety of procedures, i.e. liposuction, tummy tuck, nose correction, face lift, etc.  These procedures are not cheap.  For example, a liposuction, which is essentially a fat reduction procedure in the areas of the thighs, hips, abdomen, knees, and face, may cost between $1,500 and $6,000.  A face lift, which is the tightening of the skin and facial muscles while excess skin is removed, runs from $2,500 to $8,000, and quite possibly higher. 

In general, insurance companies do not cover cosmetic surgery unless it is deemed to be medically necessary. Medical necessity is not always easy to ascertain, but as a rule of thumb, if the cosmetic surgery to be performed necessitates reconstructive surgery in the wake of trauma, tumors, infection, developmental abnormalities, or congenital disease, the patient will have the good fortune of having the insurance company foot the bill.  Conversely, if the patient is not able to establish medical necessity, the insurance company will consider the treatment to be an elective procedure and will not be obligated to pay anything.

So as to qualify as a reconstructive surgery rather than an elective cosmetic procedure, the operation must be performed in order to improve a body part’s functions, but quite often it is accepted if the surgery is merely used to give the body part a societal accepted normal appearance. Yet, the buyer must beware!  While insurance companies will quite often cover such reconstructive surgery, they may not cover it to the extent the patient wishes the surgery to go.  

One of the procedures that are quite often covered is ear surgery, also known as otoplasty. In the course of this surgery, prominent ears are set back to lie closer to the head; in some cases, the size of overly a large ear is drastically reduced.  When this surgery is done on children, the insurance companies quite often cover it; when it is done on an adult, the patient will have the obligation of proving the reconstructive aspect of the treatment as opposed to the cosmetic angle.

Another cosmetic surgery that may be covered by insurance is eyelid surgery (blepharoplasty), which corrects drooping upper eyelids, or puffy bags below the eyes.  This is accomplished by removing fat, skin, and muscle that cause the undesired drooping/puffing. This surgery may be covered if the patient can prove to the insurance company‘s satisfaction that it is deemed to be medically necessary to correct visual field defects.

Nose surgeries, also known as rhinoplasties, accomplish a wide variety of effects, such as the reduction or increase in the nose’s size by simple reshaping, the removal of a prominent hump, or the correction of a previously broken nose.  If the surgery is a reconstruction due to damage to the nose, it will most likely be covered by the insurance company.  Otherwise, the patient will need to establish that the procedure is not simply an esthetically motivated treatment, but actually offers a medical benefit, such as the relief of breathing problems.

Insurance companies in many ways still have the upper hand when deciding whether or not to cover a cosmetic surgery.  Policies are plentiful and vary from plan to plan, yet the American Medical Association and the American Society of Plastic Surgeons set a guideline that is generally followed forth.

If the aforementioned entities declare a procedure to be a reconstructive surgery, which does not necessitate a causal event but may easily apply to a simple improvement of function of the body part in question, then the insurance companies will be more likely to consider the claim for payment.  If, however, a procedure is considered devoid of medical benefits and is simply deemed elective for the sake of improving a patient’s self-esteem or body image, the insurance companies will be very hesitant to even accept the claim.