Your health insurance policy may pay for plastic surgery. It depends on the terms of your plan and what type of procedure you're getting.
According to the American Society of Plastic Surgeons, Americans spent more than $16.5 billion on cosmetic plastic surgery in 2018. That comes out to a lot of money in doctor fees and medical bills. So, who is paying the costs? Is it patients or their insurers? The answer is: it depends.
When Does Health Insurance Cover Plastic Surgery?
- Essential to a body function or your quality of life
Insurance policies can vary on what they will cover. But, there are some rules most insurers follow.
Reconstructive Surgery vs. Cosmetic Surgery
Most insurers follow the definitions given by the AMA (American Medical Association) and the American Society of Plastic Surgeons (ASPS). These guidelines say what types of surgery are reconstructive and what types are cosmetic.
- Reconstructive surgery is performed to correct issues caused by disease, infection, or trauma. It is meant to improve function or restore normal appearance.
- Cosmetic plastic surgery enhances appearance for aesthetic reasons.
What Is Considered Medically Necessary?
What is considered cosmetic vs. medically necessary? It's up to the insurer. It may also change over time based on:
- The type of insurance
- New research
- New treatments
Common Procedures That May Be Covered
Many procedures that could seem to be purely cosmetic might be covered by your insurer. It depends.
For instance, abdominal surgery might be covered if you have back pain or if it improves your ability to walk. Breast surgery might be covered to reduce large breasts that cause back pain. Eyelid surgery might be covered to correct drooping eyelids that cause loss of sight.
If you feel that a problem is affecting your health, speak with your doctor. They can confirm if it would be considered reconstructive. Your doctor can also help you with your insurer.
Examples Not Likely to Be Covered
Elective cosmetic surgery is not covered in most health insurance plans. This is because it is optional. It is not considered a medical necessity.
Here are surgeries that are often not covered:
- Breast augmentation
- Eyelid surgery
Weight-loss surgery may or may not be covered. For instance, if you are considered morbidly obese, your insurer may cover the surgery. Ask your insurer for more insight.
Non-Cosmetic Plastic Surgery That May Be Covered
If you need a procedure to preserve the healthy functioning of your body, then it is not cosmetic. If you are injured in a car accident and your body needs to be repaired, for instance, that would likely be covered.
But, an insurer may require that you exhaust non-surgical fixes first.
Keep in mind that each health insurer has its own rules. It may restrict procedures, or exclude them.
Example of a Nose Job That May Be Covered
Julie has a great deal of trouble breathing. She doesn't sleep well, and her health suffers as a result. She finds out that she has a deviated septum. If the doctor shows that this is a needed surgery, then the work she has on her nose may be covered.
Example of Breast Surgery That May Be Covered
Susan has very large breasts that cause her extreme discomfort. She has severe shoulder and back pain. Her quality of life is impacted. Her doctor does a full exam to find the source of the problem. The issues are being caused by the weight of her breasts. Her doctor recommends a breast reduction.
Susan discusses the matter with her health insurer. She is required to submit various forms from her doctor. At first, the insurer declines coverage. They suggest that physical therapy might solve the issue.
Susan follows these instructions for almost a year. Once physical therapy fails to solve the problem, she is able to request reconsideration.
Susan then completes a new series of forms from her doctor. After looking at them, her health insurer agrees that this is not a cosmetic procedure. They advise Susan that it will be covered under her plan.
How Insurers Evaluate Plastic Surgery Differently
A few months later, Susan's friend gets the same diagnosis. She applies to have the same procedure covered and is turned down. Her insurer does not view it as essential. She winds up paying out of pocket. Her bill is $10,000.
How to Make Sure Your Plastic Surgery Is Covered
- Contact your plan administrator. Find out what coverage you have for plastic surgery.
- Get an estimate so you can review this against your policy.
- Find out what your deductible would be.
- Find out if they expect you to pay a percentage of the bill.
- Find out what medications will be covered.
- See if the insurer may pay for half of your procedure as medical benefits. In this case, you would pay half as cosmetic. Your doctor may be able to help you here.
- Get the details in writing.
Always check with your health insurer. Be prepared before you file your health insurance claim.