Your health insurance policy may pay for plastic surgery depending on the terms and conditions of your health insurance plan if the surgery is considered reconstructive and non-cosmetic.
According to the American Society of Plastic Surgeons, Americans spent more than 16.5 billion dollars on cosmetic plastic surgery in 2018. That comes out to a lot of money in doctor fees and medical bills, so who is paying for plastic surgery costs? The answer to this question depends on several factors.
When Does Health Insurance Include Coverage for Plastic Surgery?
Who pays for plastic surgery costs depends on your insurance company, and the type of health insurance you have as well as how the procedure you need is defined. To determine if the procedure will be covered, It is important to find out if:
- the surgery is cosmetic
- or essential to a body function or preserving your quality of life
The answers to these questions are part of the process to determine if it will be covered.
Although insurance policies can vary concerning what is considered a covered procedure, there are some guidelines most insurance companies adhere to when it comes to definitions of what is considered reconstructive or necessary and what is considered cosmetic.
The Definitions Necessary to Understand What Is Covered or Not Covered
Most insurance companies follow the definitions given by the AMA (American Medical Association) and the American Society of Plastic Surgeons (ASPS) to distinguish between reconstructive surgery, cosmetic surgery, and what may be considered medically necessary or not. For example:
- Reconstructive surgery refers to surgery performed on abnormal structures caused by congenital disabilities, developmental abnormalities, trauma, infection, tumors, or disease. This category can include surgery to improve function or to give a normal appearance.
- Cosmetic plastic surgery includes surgical and non-surgical procedures that enhance and reshape structures of the body to improve appearance and confidence.
What Is Considered Cosmetic vs. Medically Necessary?
What is considered cosmetic plastic surgery vs. medically necessary is entirely up to the insurance company who holds your policy and may change over time, based on:
- the type of insurance you have,
- research and how they relate to patient needs
- the evolution of new procedures and medical treatments.
Examples of Costs and Common Procedures That May Be Covered
Here is a list compiled with information from ASPS regarding surgery that your insurance company may consider covering:
- Abdominal Surgery: If performed to improve or eliminate health problems such as back pain, sores, hernia, rashes, or help improve the ability to walk normally.
- Breast Surgery: If performed to correct asymmetry, reduce large breasts causing health problems, reconstruction due to loss, congenital absence (was born with only one breast), or reduce large male breasts.
- Ear Surgery: If performed to correct deformed ears by birth, disease, or injury.
- Eyelid Surgery: If performed to correct drooping eyelids that are causing vision problems or correct eyelids that are turned in an abnormal way.
- Facial Surgery: If performed to balance the appearance if caused by paralysis, treat deformities in the facial muscles, head, or neck.
- Hand Surgery: If performed to treat carpal tunnel syndrome, Dupuytren's contracture, nerve injuries, tendon injuries, fused fingers, or other deformities.
- Nasal Surgery: If performed to correct deformities resulting from birth, disease, or problems with breathing.
If you feel you may fall into any of these categories, it is important to speak with your doctor. Your doctor can confirm if your condition would be considered reconstructive and can help you with contacting your insurance company.
Examples Not Likely to Be Covered
Since 1997, the number of cosmetic procedures performed among women increased by over 538%—325% for men—according to the ASPS 2015 statistical data. It makes sense that people are looking to receive compensation from their health insurance for any procedure that their health benefits plan may cover.
Unfortunately, elective cosmetic surgery is not usually covered in most health insurance plans because it is optional and not usually considered as a medical necessity to maintain the quality of life or body functioning.
Here are examples of surgeries that are not routinely covered by health insurance, although exceptions due to extraordinary circumstances may apply.
- Breast Augmentation
- Eyelid Surgery
Example of Health Insurers Using Psychiatric Evaluations to Qualify Procedures Including Weight-Loss Surgery
Although liposuction and tummy tucks are normally considered cosmetic, there are exceptional circumstances where the health insurer may allow consideration of medical procedures to be covered by the health insurance benefits. For example, in the case of someone who is considered morbidly obese and has had psychiatric evaluations showing that the excess weight is affecting the quality of life they are leading. However, this is usually only approved after a long-term evaluation, combined with doctor monitored programs to first try and address the issue with non-surgical weight-loss programs and other methods. Weight-loss surgery is not normally covered and requires a truly exceptional circumstance.
Examples of Non-Cosmetic Plastic Surgery That May be Covered
If a plastic surgery procedure is required to preserve the healthy functioning of the body, then it is not purely cosmetic. Procedures following car accidents, major accidents, or situations where your body needs to be repaired so that you may resume "quality of life and body function " would likely be covered by your health insurer if you have a comprehensive plan.
If a doctor identifies a procedure as necessary to live properly, this would likely not be considered cosmetic. However, an insurance company may require that non-surgical solutions be exhausted before the procedure is approved.
Keep in mind that each health insurance company has it's own coverages and may restrict procedures, or exclude them. You must first find out if your health insurance company covers non-cosmetic plastic surgery. Always check this before any procedure so that you do not incur unexpected costs.
Example of a Nose Job That May Be Covered
Julie has a great deal of trouble breathing. Normally, she doesn't sleep well, and her general health is affected. She finds out that she has a deviated septum causing the problem. If the doctor shows that this is a necessary surgery and not a cosmetic one, then the work she has on her nose following the correction of her deviated septum may fall under covered plastic surgery.
Example of Breast Surgery That May Be Covered
Susan has very large breasts that cause her extreme discomfort and make it difficult for her to participate in various physical activities. She experiences severe shoulder and back pain, and her quality of life is significantly impacted by the situation. After her doctor did a full examination to determine the source of the problem, her doctor explained that the issues were being caused by the weight of her breasts, and recommended a breast reduction surgery.
Susan discussed the matter with her health insurance company and was required to submit various forms and additional information from her doctor. They initially declined coverage, suggesting that physical therapy or chiropractic care or pain medications might solve the issue.
Susan followed these instructions for almost a year, and only once physical therapy and all alternative methods did not solve the problem, was she able to request reconsideration.
Susan then completed a new series of forms and information from her doctor again. After reviewing the information, her health insurance company agreed that this was not a cosmetic procedure and advised Susan that the procedure would be covered under her benefits.
Example of How Insurers Evaluate Plastic Surgery Differently
A few months later, Susan's friend experiences a similar diagnosis, she applies to have the same procedure covered and is turned down, she discovers that her insurance company does not view the procedure as essential. So she would end up paying the procedure entirely out of pocket, which costs her $10,000. She was glad she found out in advance from her health insurer that she would not qualify for health benefits coverage on the surgery.
How to Make Sure Your Plastic Surgery Is Covered Before You Schedule a Procedure
- Contact your health insurance plan administrator or insurance company directly and find out what coverage you have for plastic surgery procedures
- Get an accurate estimate with detailed costs prediction for your plastic surgery procedure so you can review this against your policy coverage
- Find out what your deductible would be in the event of coverage
- Find out what the maximum amount payable is, and if they expect you to pay a certain percentage of the procedure
- Find out what related medications like painkillers would be covered
- Consider if the insurance company may pay part of your procedure by going in for half as medical benefits, and you may pay the half cosmetic. Your doctor and specialists may be able to help you here.
- Get the details in writing of your coverages, so you are not surprised. Never assume anything is covered unless your health insurance company confirms it.
Situations like this make the coverages included under a health plan difficult to define. Always check with your health insurer before you make any assumptions. It is hard to determine what is considered necessary or simply cosmetic. In some cases, only parts of surgeries may be covered, which makes it more complicated. Be prepared before you try and file your health insurance claim.