Considering how expensive medical insurance premiums are, you’d think insurance companies would cover plastic surgery. Unfortunately, you’re probably on your own when it comes to paying for physical improvements. Sure, your self esteem might get a boost after that bump in your nose is corrected, but that doesn’t mean Blue Cross will be sending reimbursement. However, there are cases where insurance for plastic surgery is possible. Maybe one of these examples applies to you or a loved one.
No Coverage for Cosmetic Surgeries
In 1989, the American Medical Association (AMA) drafted a set of guidelines distinguishing cosmetic and reconstructive surgery. The American Society of Plastic Surgeons (ASPS) follows these directives, which explain that “cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.”
When people think of “plastic surgery,” they usually think of cosmetic surgery rather than reconstructive surgery. Although you might feel that a tummy tuck is a matter of life or death, chances are it isn’t. It’s definitely popular––in 2019, the ASPS estimated that almost $17 billion had been spent on cosmetic procedures in the U.S. alone. It’s a growth industry––with the number of cosmetic procedures performed among men growing by 325% between 1997 and 2015, while increasing by 538% for women. It’s also entirely optional.
Third-party payers––usually insurance companies––generally rely on the AMA’s definitions when they decide what services are eligible for coverage under the plans they offer or administer. Although Health Savings Accounts cover expenses outside of normal insurance, they can’t be used for cosmetic procedures either. There are ways to finance these including in-house loans offered by the surgeon. This sort of loan often doesn’t require collateral or a credit check. You can also apply for a line of credit from your bank or even get a CareCredit® medical credit card.
Reconstructive Surgery and Insurance
Surgeries considered reconstructive are in a different category. If you’re injured in an accident or other trauma, your insurance carrier will usually cover plastic surgery. If it’s the result of another person or company’s negligence, then they could be liable for the costs. Plastic surgery is also covered when it is used to repair birth defects. For adults, some examples of cosmetic procedures that might be covered include ear surgery done to correct deformities caused by accidents, trauma, or birth; surgery to reduce breast size if they are causing health problems or for males, and facial surgery to correct paralysis. Although tummy tucks and gastric sleeves are often seen as cosmetic, for patients with body mass indexes over 30 they are considered life-saving and may be covered. Procedures addressing appearance following drastic weight loss can also be covered in many instances. Sometimes, the insurance company has to be lobbied in order to get it to agree to pay. Besides photographic evidence, psychiatric testimony dealing with quality of life is sometimes necessary. The ASPS offers a long list of insurance guidelines for individual procedures.
Women who need reconstructive surgery and implants following a mastectomy are protected by U.S. law. This is because in 1998, Congress passed a bill requiring group health plans that covered mastectomies to also cover reconstruction––which can include breast implants. Medicare offers coverage for post-mastectomy, bilateral breast reconstruction.
If you believe your insurance company has wrongly denied your claim, remember you do have options. Sometimes you may need to consult an attorney. In many cases, necessary plastic surgery can change your life.
Written by John Bankston
References
- The effects of cosmetic surgery on body image, self-esteem, and psychological problems
- Definitions of “Cosmetic” and “Reconstructive” Surgery H-475.992
- Plastic Surgery Statistics Report
- Cosmetic Surgery National Data Bank Statistics
- ASPS Recommended Insurance Coverage Criteria
- Women’s Health and Cancer Rights Act
