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Does Health Insurance Cover Plastic Surgery

Insurance Companies That Cover Bariatric Surgery In The United States

Does Health Insurance Cover Cosmetic Surgery? Health Insurance, Cosmetic Surgery by Dr PK Talwar

Almost all insurance companies in the U.S. have policies that cover bariatric surgery. Whether you have insurance that covers bariatric surgery depends on what type of policy you have:

  • An Individual/Family or Small Group Policy covers weight loss surgery if you live in one of the 23 states that mandate it
  • A Large Group Policy covers bariatric surgery if your employer has chosen to include it in your plan
  • Medicare covers weight loss surgery
  • Medicaid covers weight loss surgery

If your insurance policy covers weight loss surgery, insurance will only pay for it if:

  • You have a qualifying body mass index of 35+ with obesity-related health problems or a BMI of 40+
  • You participate in a medically supervised diet program before having the procedure

Scroll down for the full bariatric surgery insurance coverage list by U.S. Insurance company.

For more information about plan types and general bariatric surgery insurance qualification requirements, see our Bariatric Surgery Insurance page.

How To Get Insurance To Pay For Plastic Surgery

The trick to getting health insurance to pay for plastic surgery is to ask the right questions. Unfortunately, many patients begin with misconceptions about how the process works.

  • The incorrect question is what insurance company covers plastic surgery
  • The correct problem is how do I demonstrate the medical necessity so that the underwriting department will preauthorize the procedure and honor the subsequent claim

Have Additional Questions About Plastic Surgery Procedures And Insurance Coverage

As we mentioned, your insurance company is the best resource when it comes to determining whether or not a specific plastic surgery procedure will be covered. However, if youd like to set up a consultation with us to discuss your plastic surgery goals before reaching out to your insurance company, wed be more than happy to meet with you!

Weve been providing high quality plastic surgery and cosmetic surgery services to clients in Glens Falls, Saratoga, the Adirondacks and beyond for more than a decade! If youre ready to take the next step towards looking and feeling your best, wed be happy to partner with you on the journey.

Schedule an appointment with us today! Give us a call at or contact us online to get the conversation started.

Looking for additional information about cosmetic procedures and what to expect when it comes to plastic surgery? Be sure to check out the cosmetic procedures section of our blog for valuable insight from our experienced team.

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What Are The Out

There are some outpatient plastic surgery procedures that are covered by Medicare, such as rhinoplasty. These outpatient procedures are done in an outpatient clinic, and you can return home the same day as the surgery.

However, most medically necessary plastic surgery procedures are inpatient procedures. These procedures require overnight hospitalization. Some examples of inpatient plastic surgery procedures that Medicare may cover include:

  • cleft lip or palate surgery
  • facial augmentation
  • prosthetic or tissue flap breast reconstruction
  • upper or lower limb surgery

Whether you require inpatient or outpatient surgery, here are some of the out-of-pocket costs you may encounter, depending on your coverage.

Eyebrow / Eyelash Tattooing

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Yang and colleagues reported on 2 patients with epithelioid granulomatous inflammation on the eyebrows after undergoing cosmetic eyebrow tattooing. These investigators analyzed the causative elements from biopsy specimens and tattoo inks with X-ray micro-analysis. The authors suggest that granuloma caused by cosmetic eyebrow tattooing was a complication worthy of mention.

Ro and Lee reported one case of epithelioid granuloma that occurred at the site of a previous cosmetic eyebrow tattooing. A biopsy specimen showed the organized appearance of epithelioid cell granulomas containing little pigment as well as occasional giant cells, primarily of Langhans’ type thus, showing the characteristic features of granulomatous hypersensitivity. With the use of energy dispersive X-ray micro-analysis and inductively coupled plasma spectrometry, the presence of copper, iron, cobalt, and chromium was demonstrated.

Lee and associates noted that eyebrow and eyelash tattooing are commonly performed procedures that have a very low rate of reported complications. These investigators described 1 case of infra-orbital pigmentation following eyelash tattooing and another of peri-orbital pigmentation following eyebrow tattooing. The authors concluded that although most complications related to eyelash and eyebrow tattooing, including pigment fanning, have been reported by ophthalmologists, pigment fanning was also of concern to dermatologists.

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Reading Your Own Policy

Its important to understand whats included in your policy before you advance too far in planning surgery. Some policies provide coverage for many plastic surgery procedures while others are more limited in coverage. Read your policy and benefits manual carefully and discuss any questions you may have with your insurance plan manager.

There are three typical cost sharing options:

  • A deductible, is the total amount of covered medical expenses that must be paid by the patient before the insurance company begins paying benefits. Examples of standard deductibles are $100, $250, or $500. After this requirement is reached, the insurer will begin paying according to terms of the contract-often 75%-85% of covered medical costs. The patient is responsible for any remaining balance.
  • A flat-rate copayment, reflects a defined share of covered medical costs that the patient pays, with the insurance carrier paying an amount based on the patients policy. For example, when the patient pays $15 of any office visit charge or $3 for any prescription, the insurance carrier is responsible for the balance.
  • A percentage-based copayment, reflects a percentage share of covered medical costs that the patient pays, with the insurance company paying an amount based on the patients policy. Examples are: 20% of the office visit charge $10 of a $50 charge, $12 of a $60 charge, etc. Typically, this copayment arrangement includes a deductible and may have other variations.

Medically Necessary Plastic Surgery

The first step is to determine if a specific plastic surgery is medically necessary, since this is often a requirement for insurance coverage. Medically necessary is not strictly defined and will vary among insurance companies, specific procedures, and circumstances of each patient. If your procedure is medically necessary, some portion of the plastic surgery cost may be covered.

Generally speaking, reconstructive surgery is considered medically necessary while cosmetic surgery is not. Reconstructive surgery is required for conditions that often arise from congenital defects, developmental abnormalities, trauma or injury, infection, tumors, or other diseases. Reconstructive surgery may improve function, ex. breathing through the nose with rhinoplasty, in addition to improving form or appearance.

Breast reduction to treat back pain can be considered medically necessary. Rhinoplasty to improve the sinus passages is another example that may be considered a medical necessary procedure. However, circumstances will vary with each patient. In addition, specific coverage comes down to ones particular insurance carrier and individual plan.

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What Cosmetic Procedures Are Covered By Insurance

Its certainly a relief to know that some cosmetic and plastic surgeries will be covered by insurance, at least in part, given the large cost of these procedures. For example, a nose job usually costs around $5,000 and breast augmentation costs $3,700 per breast.

The extent of your coverage will depend on your specific insurance policy. However, the general rule of thumb is that insurance will pay for procedures that are deemed medically necessary.

That means that if you want breast augmentation just because youd like larger breasts, then your insurance will not help out. But if you require breast augmentation after having a mastectomy, then your insurance will likely help cover the cost.

Different Insurance Plans and Their Cosmetic Coverage

  • Employer Sponsored Plans: In these plans, cosmetic surgery is only covered if a doctor or physician deems the surgery medically necessary.
  • On/Off Marketplace Plans: Cosmetic surgery is not one of the ten essential health benefits that all of these types of plans are legally required to offer. However, depending on which plan you purchase, medically necessary procedures to repair birth defects or reconstruct damaged body parts may be covered.

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List Of Examples Likely To Not Be Covered By Health Insurance

When does Insurance cover Cosmetic Eyelid Surgery or Blepharoplasty?

Although this list could be much longer, were addressing the more common requests that dont go through the insurance claim approval:

  • Lip or Butt Injections

Keep in mind that insurance providers will cover some of these procedures in certain cases. This typically happens because the damage resulted from trauma, a major accident, or are severely impacting the persons quality of life.

If you believe that you fall into the small percentage of people who should receive these procedures with the bill covered by health insurance you need to contact your insurance company, every company has their own policies in place that dive into what exceptions they do or do not allow.

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Why Are Some Plastic Surgery Procedures Covered By Insurance While Others Are Not

As mentioned previously, there are a number of factors that impact whether or not a plastic surgery procedure will be covered by health insurance.

Your specific health insurance policy may or may not include coverage for plastic surgery. As such, coverage can depend on the provider and policy.

Additionally, the reason for the plastic surgery is typically one of the deciding factors for insurance companies. If a procedure is elective or optional, it likely wont be covered. If the procedure is considered to be purely cosmetic, most health insurances wont cover the cost.

On the other hand, if a procedure is considered to be medically necessary or reconstructive in nature to correct defects or abnormalities caused by certain conditions, diseases, illnesses, or accidents, that procedure may be covered by health insurance. Your insurance company will be the one to determine whether or not your procedure is considered cosmetic and elective or medically necessary.

Given that the circumstances surrounding the procedure, the type of procedure, the insurance policy coverage, and other factors impact whether or not the surgery will be covered, its incredibly important to work with your insurance company to know what to expect. In most cases, they will be the ones to ultimately determine what will be covered in your specific situation.

Health Insurance Plans That Cover Lasik Laser Eye Surgery

LASIK Surgery is the most popular refractive eye surgery which aims to correct your vision. In other words, no more spectacles and contact lenses. The surgery is expensive and having your health insurance cover Lasik eye surgery will come very handy. But most health insurance dont cover Lasik treatment as it is considered a cosmetic surgery.

However, things are changing and now, some health insurance plans cover Lasik eye surgery. In this article, we see which eye surgeries are covered by mediclaim policies and the terms & conditions under which Lasik surgery is covered under health insurance.

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Repairing A Malformed Body Part To Improve Function

Birth defects, aging, and disease can all impair proper functioning of some body parts. Congenital or developmental abnormalities can also affect the way certain body parts are formed. Diseases are yet another possible cause of abnormal body structure and lack of function. In some cases, plastic surgery can be used to help improve the function of these affected body parts.

Does Health Insurance Cover Cosmetic Surgery

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Millions of Americans go under the knife every year to enhance their appearance in one way or another. Does health insurance cover those procedures?

Will your health insurance plan help you pay for that nose job youve always wanted?

Or will it cover an eyelid lift, breast augmentation, tummy tuck, or butt lift?

The answer to these questions depends mostly on what kind of insurance policy. Most cosmetic surgery, however, isnt covered by insurance. There are exceptions:

  • If the goal of the surgery is to enhance or improve your appearance, dont expect your insurance plan to pay for it.
  • If its aim is to repair a congenital defect or reconstruct a body part damaged by a burn, disease, or some sort of trauma, your policy may help out.

Thats just the gist, though. Keep reading to learn more about:

  • How various types of health plans treat cosmetic and plastic surgery.
  • Common exceptions
  • How to find out if your health insurance will or wont cover a procedure.
  • Your options if your insurance policy wont the procedure you need or want to have done.
  • How much you might pay for plastic or cosmetic surgery .

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Limitedbreast Implant Complications And Breast Reconstruction

Breast implants arent always a one-and-done surgery. In some cases, they contract, rupture, cause pain, get infected, and do all sorts of things they arent supposed to do, says Dr. Cassileth, who has had breast augmentation patients whove needed 10 surgeries to correct their implants.

In the case of capsular contracture , the contracture is measured on a scale from Grade I to Grade IV. Grade IV means a very hard implant and is usually covered by insurance policies, says Dr. Cassileth. However, your insurance will cover only the capsulectomy and pain medications. It wont cover the new replacement implant or the acellular dermal matrix that may be used to shield it.

The removal of implant can also be covered, in the case of an infection, meaning your breast is red or has a sore spot, or if a silicone implant has ruptured. Finally, the Womens Health and Cancer Rights Act of 1998 requires all group health plans that pay for a mastectomy after a breast cancer diagnosis to also cover prostheses and reconstructive surgery procedures.

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Letter Of Medical Necessity

Composing a letter of medical necessity is critical to getting your health insurance plan to cover any plastic surgery. Your physician composes and signs the letter of medical necessity demonstrating that the procedure treats a disease or medical condition.

The insurance company may require the letter before issuing a preauthorization and paying the claim submitted by your provider. Ensure that the document includes supporting .

  • Unnecessary: cosmetic surgery that reshapes healthy tissue to improve appearance or symmetry
  • Necessary: plastic surgery that reconstructs facial and body defects caused by congenital deformities, accidents, or illnesses

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Why Do People Have Them Done

For many of us, our physical appearance affects how we see ourselves and how others see us. The size, shape, and look of our bodies may affect how we feel about ourselves and even how we live our lives.

There is nothing wrong with wanting to change the way you look. Some people do this through diet, exercise, and other lifestyle changes. Others have cosmetic surgery, especially if they are unhappy with a certain part of their body or appearance that can be changed.

Failure Of Conservative Measures

What plastic surgery procedures are covered by insurance?

Another important criteria that insurance companies now consider is whether other courses of treatment have already been tried. For example, has the patient been prescribed medication, have they had physical therapy, or other procedures?

If other potential treatment options have been tried without success, the insurance company needs to hear that surgery is not the first attempted solution, and that plastic surgery is the only treatment option left.

The best way to communicate that is to show we tried all of these other alternatives and nothing worked, says Michaels. This is also known as a failure of conservative measures.

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Staying Informed About Your Health Care Costs

As you plan for plastic surgery, you will probably learn a lot about what will happen in the operating room and discuss with your plastic surgeon how you will look and feel afterward. However, another important part of being an informed patient is knowing about the costs associated with surgery, and how these costs will be paid.

The American Society of Plastic Surgeons has prepared this information to assist you in better understanding health insurance benefits for plastic surgery. It is intended to answer basic questions and guide you in communicating effectively with your plastic surgeons office staff and your insurance carrier. It wont answer all of your questions, because a lot depends on individual circumstances and your own insurance. Be sure to contact your insurance company or your employers Human Resources/Benefits department with any questions you have about coverage for specific services.

The Difference Between Medical Necessity & Cosmetics

This is up to the insurance companies to decide what is medically necessary and what will come under the category of cosmetics. In fact, they can change their policies from time to time depending on the following:

  • How they relate to the needs of the patients
  • Evolution of the new procedures
  • Requirements for medical treatment

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The Appeals Process: Another Chance At Coverage

If your insurance company does not authorize payment for your reconstructive surgery, or if it agrees to pay only a small percentage of a claim, you may choose to appeal the decision.

Before beginning this process, carefully read your policy or benefits booklet. Make sure there is nothing in the plan that specifically excludes the type of care you received or are scheduled to receive.

In appealing the decision, your first step is to write a letter to the insurance company representative who signed the notification of denial. In the letter, explain why you feel the procedure should be covered and ask that your request be reviewed by a plastic surgeon certified by the American Board of Plastic Surgery.

Your appeal letter should also request a full explanation of why coverage is being denied or paid at a reduced level. Request that the claims supervisor send you a copy of the specific statement drawn from the policy or from the benefits booklet that explains why your coverage is limited or denied. Attach a copy of the denial notification and a copy of your doctors pre-authorization letter to again provide the statement of your surgeons fee, the applicable billing codes, and an ASPS Position Paper specific to your procedure. Position papers are available from your plastic surgeon.

If your insurance company responds favorably to your appeal, notify the commissioner of your successful appeal efforts with a second letter.

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