Will my insurance cover this procedure

As a plastic surgeon, this is a question my office gets every week. Will my insurance cover a certain procedure? It seems like it should be a very straightforward question, but as you might suspect, nothing is straightforward when it comes to health insurance. Before I endeavor to make some sense out of this topic, allow me to say that the health insurance industry’s only goal is to make money, not to ensure your healthcare. It makes money by charging premiums and then not paying doctors and hospitals when you want a procedure covered. So when it comes to plastic surgery, it will do everything it can do to say a certain procedure is not medically necessary, and therefore, not covered. In the past few years, getting previously covered procedures approved has become harder and harder. It used to be that doctors would get authorization or pre-approval from insurance companies and that would guarantee that the procedure would get covered. Now many companies are saying “pre-authorization not required”. While this seems great at first, doctors, patients, and facilities have found out the hard way that this really means “proceed at your own risk”. For example, I’ve had multiple patients have a procedure performed only to get a bill from the hospital saying the insurance company has refused payment when they said “pre-authorization not needed”. This has become such a problem that many hospitals and centers are making patients pay ahead of time for certain procedures that are not getting covered routinely. All of this has led some plastic surgeons to stop accepting insurance all together.

Surgical procedures are covered if they are deemed medically necessary. Some plastic surgery is routinely covered, such as trauma, cancer, burns, and wounds. Some plastic surgery is always considered cosmetic and therefore never covered: for example, tummy tucks, liposuction, and injectable fillers. To complicate things, now many policies have small print “exclusions” for common procedures like breast reduction, meaning they are never covered under any circumstance, even if medically necessary. Here are a list of the common procedures that fall in the grey area of medical necessity:

Breast reduction- Most insurance companies will cover this procedure if the patient has symptoms related to overly large breasts and a certain amount of breast tissue by weight needs to be removed. The higher your body weight, the more needs to be removed. Of course, this amount is different for every woman. But in general, going from a DD to a C cup is not going to be covered. Going from a G to a C would be. Typically at least 500 grams (Slightly over one pound) needs to be removed from each breast from a woman who weighs under 175 pounds. Each insurance company has their own formula and your doctor can help you understand if the procedure would be covered.

Rhinoplasty- Rhinoplasty is covered only if there is breathing impairment, such as a severely deviated septum. Oftentimes, insurance companies will requre CT scans to validate this finding.

Upper eyelids- Upper blepharoplasty may be covered when the excess skin impairs vision. This must be verified through a visual field exam done by an independent optometrist. Even when visual field defects are verified, the procedure often doesn’t get paid by the insurance company. Ask me how I know.

Removal of excess skin following weight loss- With the recent increase in weight loss surgery, we are seeing more patients who have lost 100 or more pounds coming in with the desire to have the excess skin removed from their trunks, arms, and legs. The only procedure which we can sometimes get covered is a panniculectomy. A panniculectomy is surgical removal of the overhanging skin of the lower abdomen. But there must be documentation of severe skin infections and/ or open wounds. Even when these conditions are met, many insurance companies treat this like a tummy tuck and simply refuse to pay.

Botox- We all know about the cosmetic benefits of Botox, but there are some medical indications as well including migraine treatment. But this requires extensive documentation from the doctor managing your migraines and IF the doctor injecting Botox gets paid, it can take months. So most doctors, myself included, do not accept insurance for medically indicated Botox.

Breast cancer reconstruction- The good news here is that so far all procedures relating to breast cancer reconstruction are covered. This includes treatment of the opposite, non-cancerous breast to maintain symmetry. So in the case of breast cancer, breast implants, lifts, and reductions may all be covered.

If you have any more questions regarding the insurance coverage of plastic surgery procedures contact my office at 301-829-4110. I accept most insurances. For now….


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