Elective Plastic Surgery and Health Insurance Coverage

Posted By on Jan 22, 2014 in Uncategorized | 0 comments


Health insurance in the US rarely covers the cost of elective plastic surgery, also referred to as cosmetic surgical enhancement, because it is not medically necessary so to speak.  However, a growing number of lenders and even plastic surgeons are finding ways (e.g., easy payment options) to help many patients “afford” the procedure.

By contrast, any plastic surgery performed in an attempt to improve body function and correct deformity is often covered by health insurance, although it is the task of the patient and his doctor to provide documentations proving the procedure is medically necessary.

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Aside from medical documentations and testimonies from experts claiming that a certain procedure is a reconstructive one, in many cases health insurance also requires a patient be near his ideal weight, particularly when it comes to body contouring procedures.

For instance, post-obese patients—whose apron-like skin in their abdominal area is causing tissue breakdown—are required to be at their normal, steady weight before insurance coverage for the this procedure called panniculectomy becomes a possibility.

While the panniculectomy wherein the hanging abdominal skin is removed is oftentimes covered by health insurance, most body contouring procedures for previously obese individuals such as tummy tuck and arm lift are not.

In the past, health insurance covered almost all body lift surgeries for massive weight loss patients, but then later decided to stop coverage after realizing that the looming obesity problem in the country would continue for several more years, and would strain their profit margin.

In an attempt to protect post-cancer women from the “whims” of many health insurance, regulators passed a 1998 law called The Women’s Health and Cancer Rights Act (WHCRA), which requires most group insurance plans covering mastectomy to also include the cost of breast reconstruction, which is oftentimes performed with the use of implants.

However, health insurance does not cover the cost of breast implants used solely for augmenting the bust size, which is basically just a cosmetic procedure.

Some states meanwhile also require health insurance to provide breast reduction surgery coverage to patients who meet “reasonable criteria,” i.e., breast size larger than DD that is causing chronic back/neck/shoulder pain and postural problems.

Anyone seeking insurance coverage for his plastic surgery must only consult a board-certified plastic surgeon, meaning a member of the American Board of Plastic Surgery, who can examine him and establish that a certain procedure is needed beyond cosmetic reasons.

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