Cosmetic surgery is typically performed for the purposes of changing or enhancing one’s appearance. Most of these procedures are considered elective in nature because an individual will undergo such an operation to boost his or her self-esteem and facial or body image. However, a desire to look more attractive isn’t always the core reason behind getting cosmetic surgery as many individuals who have been injured or disfigured in an accident, suffered burns to a portion of their face or body, or born with a visible birth defect often pursue methods of cosmetic improvement to repair and restore the way they look in the affected areas.
Appearance is a large part of our identities and it can shape the way each of us views ourselves as well as how others see us. That will often inspire many individuals to seek to make changes to their size, shape, and facial appearance.
However, since a majority of these types of operations are not considered medically necessary, most insurance companies will not cover the expenses that come with performing these procedures. There are some exceptions and these apply in the type of surgery that is being sought out for cosmetic intent.
Types of Cosmetic Procedures
When we’re talking about cosmetic surgery, there are two types that are commonly implemented:
- Reconstructive Surgery
This type of operation is typically performed to correct any visible scars, skin conditions, or otherwise malformed or afflicted parts of the body due to injury, disease, previous surgical procedure, or birth defect. You may feel uncomfortable about your appearance as a result of having one or more of these issues, causing emotional or psychological distress. In some cases, these problems could interfere with normal functional ability of the affected portion of your face or body. These typically warrant some medical consideration.
- Elective Surgery
This type of operation is performed strictly for improving or enhancing your appearance. Typical operations include a nose job, breast augmentation, elimination of wrinkles, removal of fat around your midsection or near your hips, among a myriad of additional procedures. The reason for going under the knife for these purposes is to boost your self-confidence by making changes to your appearance.
Insurance Coverage for Cosmetic Surgery
Since the majority of cosmetic procedures are considered elective, insurance providers do not provide coverage for getting these types of operations. The expenses that come with cosmetic surgery can become very expensive and, with the recent changes in the healthcare laws, providers are looking for any and every way to cut down on their costs.
This is particularly true since they are no longer able to deny high-risk individuals health insurance. The insurance companies are not about to take on more liability by providing coverage for costly operations that are not deemed medically vital.
However, what about those surgeries that have some form of medical necessity? It’s true that some companies will cover certain forms of reconstructive cosmetic surgery, but it can be an uphill climb to convince them of the medical necessity for any such procedure. In some instances, the medical need for reconstructive surgery can be readily apparent while in other instances it can be tough to make a case to your insurance company.
They certainly don’t make it simple to gain authorization. Even with 14 states passing legislation that mandates health insurers to provide coverage for orofacial and craniofacial cleft repair and similar facial reconstructive procedures that most policies would usually deny, there is still some difficulty in convincing insurance providers that this surgery is medically mandatory.
Most reconstructive procedures that are diagnosed and recommended to alleviate or eliminate pain, correct a medical condition, or assist in restoring the normal function of a body part are the easiest to get approved. They still, however, require an excessive amount of supporting documentation to garner proper approval from the insurer.
At the very core of the argument is the simple debate of want versus need. It is going to be virtually impossible to get your insurance company to cover a procedure you want while you may find success in getting them to provide benefits for surgery that you well and truly need in order to live a normal life.
Defining Medical Necessity
This is the most difficult component of the discussion as some conditions and afflictions could be considered more urgent than others by some medical professionals and vice versa. In many cases, two physicians could have varying diagnoses for the same issue and even more disparate treatment recommendations.
Tumors or lesions on the face are a good example. These can grow to be large in size and radically affect the facial appearance of the patient, but having them removed will likely not be covered by insurance because doing so would be considered elective. Once they are diagnosed as a potential risk for cancer, then their removal becomes reconstructive and not elective and the procedure could be covered by insurance.
Breast reduction is another example where the details can play a large part in medical necessity. If a woman is experiencing significant pain in the neck, back, or shoulders, then having the breasts reduced could be medically necessary. The patient will need to go through alternative avenues first, namely physical therapy, and prove a level of discomfort that warrants the procedure as valid for medical reasons.
A diagnosing physician would need to prove there is cause for medical intervention. If and when that is established, the size of the breast becomes the focal point and a considerable amount must be removed in order to be covered, typically a pound or more of material.
Facial features are sometimes the toughest to get approved because they are often incorrectly typified as elective in necessity. Drooping eyelids can cause problems with your sight and should be covered, rhinoplasty is not covered but septoplasty to correct a deviated septum for improved breathing can be covered. In some situations, the coverage may not be full but a percentage instead. That is, after you’ve paid your deductible and any other potential out of pocket expenses.