Will my Insurance or HMO Cover Any of the Cost of Plastic Surgery?

will my insurance or HMO cover any of the cost of plastic surgery? What are the criteria for a procedure to be covered?

Doctor Answers (2)

Insurance/HMO Will Not Cover Purely Cosmetic Procedures

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Insurance Doesn't Cover Most Cosmetic/Plastic Surgery
Forget about anything considered "Cosmetic" as no insurance will cover this unless there is significant functional reasons like  breast asymmetry (such as a congenital condition or after mastectomy for cancer). A tummy tuck will also never be covered by insurance, but occasionally a panniculectomy will. This is a term for removing only the apron of skin at the lower tummy area and only if it is very severe and causes problems like recurrent infection, rashes, etc .This procedure is done for medical indications and not for cosmetic reasons.
On the other hand a major Breast Reduction may be covered by insurance. Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company. Contact your individual company and request their specific Criteria.
Insurance company favors approval for patient with functional problems like the ones you mentioned - back, neck and knee problems, bad posture, inability to  run , etc.
The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc.
Your plastic surgeon will then contact your insurance company for preauthorization.
Here is some general information however to help you :Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth).  In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities.  Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month.  Each insurance policy has different guidelines and exclusions.
This procedure is commonly covered by insurance though insurance criteria are becoming more and more restrictive


Orange County Plastic Surgeon
5.0 out of 5 stars 38 reviews

Will HMO insurance cover cosmetic or plastic surgery

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Technically speaking most HMO insurance will not cover any cosmetic procedure. Criteria for coverage vary by carrier and will differ according to standards established for funcitonal or reconstructiive procedures for acquired or congenital conditions. There are no generalizations. Discuss your specific procedure with your primary care provider or gate keeper to ascertain eligibility for coverage of benefits.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 41 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.