When does health insurance cover elective surgery? Elective means you schedule the operation in advance at a time convenient to you and the doctor.

Your healthcare plan will cover elective procedures when medically necessary. Medically necessary means services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms.

Cosmetic surgery improves appearance. Meanwhile, plastic surgery treats conditions of injury or disease. This distinction is critically important to understand.

Therefore, make a case to your insurance company, before your scheduled operation, that the procedure treats an illness or injury. This article will show you how.

Does Private Insurance Cover Cosmetic Surgery?

Private health insurance rarely covers cosmetic surgery. Elective cosmetic procedures enhance appearance by improving aesthetic appeal, symmetry, and proportion. Enhancing appearance alone is never medically necessary.

Personal loans support monthly payment plans to finance any cosmetic procedure not covered by insurance. Patients often must fund 100% of the costs entirely out-of-pocket for LASIK, Diastasis Recti, Gynecomastia, and other procedures – except when the healthcare plan agrees to pay.

Learn about the possible exceptions before borrowing money.

LASIK Surgery

Private health and vision insurance rarely cover laser eye surgery such as LASIK or RPK. Both of these elective procedures fall into the cosmetic category because they address appearance and aesthetics only. Patients can easily wear eyeglasses or contacts to correct their vision.

However, both types of plans will often pay for some of the preliminary testings.

  • Healthcare plans often cover eye exams screening for diseases of the eye
    • Glaucoma
    • Cataracts
    • Amblyopia
    • Strabismus
    • Diabetic Retinopathy
    • Macular Degeneration
    • Ocular Nevis
  • Vision plans often pay for exams to measure refractive errors

Diastasis Recti

Private health insurance plans rarely cover abdominoplasty to correct abdominal separation of the Linea Alba. Diastasis Recti surgery falls into the cosmetic category because the removal of excess belly skin improves appearance but not a bodily function.

Therefore, Diastasis Recti is not medically necessary. However, sometimes a patient can combine this surgery with a covered umbilical hernia repair. The healthcare plan could cover some of the imaging studies, anesthesia, operating room, nursing, and other charges associated with the hernia.

Gynecomastia

Private medical insurance rarely pays for gynecomastia surgery. The enlargement of male breast tissue rarely causes any physical pain or poses any threat to a man’s long-term health. Therefore, most plans classify male breast reduction as cosmetic.

However, gynecomastia surgery is medically necessary when caused by cancerous tumors. In this case, the operative intervention hopes to cure a life-threatening disease. Therefore, expect your healthcare plan to cover the procedure. Be sure to include the diagnosis of invasive cancer when requesting pre-certification.

Insurance for Elective Plastic Surgery

Most private health insurance plans will pay for elective plastic surgery. Plastic surgery is often medically necessary because it corrects dysfunctional areas of the body.

Plastic surgeons perform medical operations that reconstruct facial and body defects due to birth disorders, trauma, burns, and diseases. Examples of covered procedures include the following.

  • Broken nose after an accident (rhinoplasty)
  • Breast reconstruction after mastectomy
  • Skin grafting and flaps for accidental burns
  • Cleft lip and palate repair

However, other procedures are less clear-cut and could fall into either camp (medically necessary or purely aesthetic). Learn how to make a case with the carrier before scheduling your elective operation.

Skin Removal

Private health insurance plans will sometimes cover skin removal surgery after significant weight loss. Plastic surgery for skin removal must resolve one or more of these conditions to fit into the medically necessary category.

  • Persistent rashes
  • Chronic yeast infections
  • Necrotizing cellulitis
  • Necrotizing fasciitis

Work with your plastic surgeon prior to scheduling the elective operation to obtain a pre-authorization from the carrier. Be sure to include these two important elements.

  1. ICD codes (International Classification of Disease) corresponding to a skin-related ailment
  2. CPT codes (Current Procedural Terminology) associated with the appropriate treatment

Breast Reduction

Individual health insurance will often cover elective breast reduction surgery when deemed medically necessary. The plastic surgeon may remove excess breast tissue to reduce chronic neck and back pain or to help clear up lingering skin rashes and infections.

Ask your doctor to draft a letter of necessity for your carrier, and ask them to pre-certify coverage for the elective mammoplasty. Do not mention your appearance in the letter. Instead, focus on the pain and long-term health effects.

Ptosis

Individual health insurance plans, as well as Medicaid and Medicare, often consider Ptosis repair (blepharoplasty) as plastic surgery. Ptosis is a drooping of the upper eyelid and can obscure vision if not corrected. The patient and oculoplastic surgeon will need to document several characteristics of the droopy eyelid to have it deemed medically necessary.

The Ptosis must meet two tests

  1. Significant obstruction of the visual field
  2. Affects the activities of daily living

The patient and the ocular doctor should present three types of documentation

  1. Doctor notes including eyelid measurements
  2. Photographs of the eyes and lids showing excess skin
  3. Visual field tests performed by an ophthalmologist

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