What Health Insurance Covers Plastic Surgery?

While often associated with aesthetic enhancements, plastic surgery also restores function, corrects deformities, or improves physical health. Health insurance coverage largely depends on the procedure’s underlying reason, specifically if it is deemed medically necessary. Insurance plans typically differentiate between reconstructive procedures, which are often covered, and cosmetic procedures, which generally are not.

Medical Necessity Versus Cosmetic Enhancement

The distinction between “medically necessary” and “cosmetic” plastic surgery is central to understanding insurance coverage. Medically necessary procedures aim to restore function, correct deformities resulting from injury, disease, or congenital conditions, or are essential for physical or mental health. For instance, surgery to repair a birth defect, such as a cleft lip or palate, would typically be considered medically necessary.

Conversely, cosmetic plastic surgery is performed solely to improve appearance without an underlying medical reason or functional impairment. Insurance companies have established guidelines to distinguish between the two, typically requiring proof that the surgery is not solely for appearance. This distinction is the core determinant of whether a procedure qualifies for coverage.

Insurance companies often consider a procedure medically necessary if it addresses a condition that significantly impacts a patient’s daily activities or quality of life. This includes issues that cause physical pain, functional limitations, or severe psychological distress directly linked to a physical deformity. Procedures performed solely for aesthetic appeal, symmetry, or proportion are usually classified as cosmetic and are rarely covered by health insurance. However, some procedures may fall into a “gray area,” serving both functional and aesthetic purposes, which requires careful review by the insurer.

Commonly Covered Reconstructive and Functional Procedures

Several plastic surgery procedures are frequently covered by health insurance when they meet specific criteria. Breast reconstruction following a mastectomy for cancer is a prime example, as federal law often mandates coverage for reconstruction and symmetry procedures on the other breast. This coverage extends to various techniques, including tissue expanders, implants, autologous tissue reconstruction, and nipple/areola reconstruction.

Another commonly covered procedure is septoplasty, performed to correct a deviated septum that causes breathing difficulties, chronic sinus infections, or sleep apnea. While standard rhinoplasty for cosmetic reasons is not typically covered, the functional component of improving airflow often qualifies septoplasty for insurance coverage. Similarly, blepharoplasty, or eyelid surgery, may be covered if drooping eyelids severely impair vision, a condition known as dermatochalasis.

Skin grafts and scar revisions are often covered to treat burns, injuries, or to remove and close lesions, masses, or skin cancer. Reconstructive surgery after tumor removal or to correct congenital anomalies, such as cleft lip and palate, also commonly qualifies for coverage. Breast reduction surgery may be covered if the large size causes documented physical symptoms like chronic back pain, neck pain, shoulder pain, or frequent skin rashes beneath the breasts. Robust medical documentation proving functional impairment is crucial for insurance approval.

Understanding Your Policy and Seeking Approval

Navigating health insurance for plastic surgery requires a thorough understanding of your specific policy and adherence to administrative procedures. Begin by reviewing your health insurance policy documents, such as the Summary of Benefits and Coverage (SBC) and Evidence of Coverage. These outline your plan’s specific coverage for reconstructive surgery, including deductibles, co-pays, out-of-pocket maximums, and in-network versus out-of-network benefits. Understanding these financial responsibilities before a procedure is important, as even covered services may incur patient costs.

Contact your insurance provider to inquire about specific procedure codes (CPT codes) and pre-authorization requirements. Pre-authorization, or prior approval, requires insurer permission before covering a surgery. The treating physician provides comprehensive medical documentation for approval, including detailed medical history, physical exam findings, photographs, diagnostic test results, and a letter of medical necessity outlining the functional impairment and why the surgery is required.

Once documentation is gathered, the pre-authorization request is submitted, including proposed CPT codes, diagnosis codes (ICD-9), estimated costs, and timelines. Insurers typically respond to pre-service requests within 15 days, or 72 hours for urgent cases. Obtain written approval before proceeding, as pre-authorization indicates intent to pay, but not a guarantee of full coverage.

If a claim is denied, you have the right to appeal. The denial letter explains the reason and appeal instructions. An internal appeal must typically be filed within 180 days of the denial notice, involving a formal appeal letter, additional medical records, and potentially a second opinion. Insurers generally complete internal appeals within 30 days for services not yet received or 60 days for services already rendered. If unsuccessful, you can pursue an external review by an independent third party, often within four months of the internal denial.