Cosmetic Surgery and Health Insurance: A Love-Hate Relationship

Elisabeth Kramer on 20 Jan 2016 at 9:30am

AvvoGuest post from Avvo written by Mary Fetzer

Cosmetic surgery is definitely not just for the rich and famous anymore. The demand for elective procedures is on the rise as we continue trying to slow the aging process and to improve our physical appearance. Countless reality TV shows enthrall us with impressive before and after surgery reveals, and the media are forever speculating about whether or not so-and-so has "had some work done."

Despite its ever-increasing popularity, plastic surgery remains a financial luxury for most. Health insurance companies dig in their heels when it comes to covering cosmetic surgery.

Will cosmetic surgery ever be more affordable for the average consumer? Will insurance companies ever lend a hand to make surgical self-improvement more mainstream? Avvo asks plastic surgeons for their professional insights.

Q: Now that cosmetic procedures have become so routine, can they be covered by an average consumer's health insurance?
"Unfortunately not," says Dr. Melissa Doft, clinical assistant professor of surgery at Weill Cornell Medical College. "Anything cosmetic is not paid for by insurance."

Unless, however, cosmetic surgery is deemed medically necessary. "Only reconstructive plastic surgery is generally covered by most major insurances," explains Dr. Norman M. Rowe, a board-certified plastic surgeon.

Paul Moyer, insurance agent and owner of SavingFreak.com, clarifies. "It varies by policy, but for most health insurance companies, coverage really depends on whether or not the surgery is elective," says Moyer. "A person getting a breast augmentation because she wants larger breasts will not be covered, while a person having the procedure following a mastectomy will be covered."

Q: How do the medical and insurance communities make the distinction between which cosmetic work is and is not covered?
The distinction is based on whether the surgery is something the patient wants versus needs. "A person who has a deviated septum and needs septoplasty is different than someone who breathes perfectly fine, but wants a smaller nose," explains Moyer.

"The definition for cosmetic surgery will certainly vary, but it essentially refers to any surgery that is undertaken merely to modify or improve the appearance of a physical feature, irregularity, or defect with no specific medical reason to do so," says Toronto plastic surgeon Dr. Mathew A. Plant. "It is a catch-all term that is easily modified to suit the needs of the person who is using the term — and this definitely differs between the medical and insurance communities."

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The disagreement usually lies in what constitutes medical need. "In my opinion," says Dr. Plant, "a medical need can include anything that causes significant physical dysfunction or psychological stress to the patient. Unfortunately, determining that is usually up to the physician, and each physician will have a different set of criteria that must be met. This makes it very difficult for insurance companies because they like to have defined criteria that their adjustors can apply to a case and unfortunately this can be very difficult at times with medical problems."

Q: As a plastic surgeon, are you surprised by which cosmetic procedures are not covered by insurance?
"The term 'cosmetic' is such a moving target that it is tough to really gauge this," says Dr. Plant. "Certain lesions, such as lipomas, may be covered, but only if they are causing pain or compressing a nerve and causing numbness; otherwise, they are certainly be considered cosmetic."

"It always amazes me when certain benign tumors, especially on the face, are not covered," Dr. Plant continues. “Under the Ontario Health Insurance Plan, where I do the majority of my work, excision of these lesions is strictly uninsured unless there is a suspicion of disease. In the case of certain lesions, like seborrheic keratoses where I know clinically there is no cancer risk, the patient has to pay out of pocket despite the fact that these lesions can grow so massive and disfiguring that a patient feels uncomfortable leaving the house."

Dr. Manish H. Shah has also been surprised by what insurance often doesn't cover. "Lipoma surgery, gum line advancement surgery, traumatic scar revision surgery, and birthmark removal surgery typically are not covered," he says. 

The insurance industry itself questions why some procedures are not covered. "Many insurance companies will cover gastric bypass surgery for someone who is morbidly obese," says Moyer, "but they are very reluctant to pay for surgery to get rid of the excess skin that remains after the weight is lost."

Q: If a cosmetic procedure that wasn't medically necessary goes wrong and leads to a medical emergency, is it covered by insurance?
"Sometimes," says Dr. Doft. "The ER visit is often covered, as is the initial hospital stay if it is necessary to stabilize the patient. For example, if a patient has a low blood pressure due to loss of blood during the cosmetic surgery, he or she may be admitted to the hospital for monitoring, and the insurance will cover the initial work-up until he or she is stable. If a patient has an infection requiring IV antibiotics after a cosmetic procedure, it is often covered. But each case varies due to the differences among insurance policies."

Elective cosmetic surgery, like any surgery, comes with risks. "Even the most carefully performed cosmetic surgery can have a complication, and many of these complications are not going to be covered by insurance," says Dr. Shah. "The ER visit will be covered in most cases, but further management will come at an out-of-pocket cost for patients."

When the insurance company does cover a surgery gone wrong, it often seeks reimbursement. "The emergency part will be covered by health insurance," says Dr. Moyer, "but will typically result in the insurance company suing the physician that botched the procedure." 

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Dr. Plant, fortunately, has never encountered a problem when dealing with emergency surgery resulting from a cosmetic procedure. "I think this is appropriate, as the whole point of insurance is to cover medically necessary procedures — and an emergency complication of a cosmetic procedure such as an infected breast implant certainly qualifies," says Dr. Plant. "Non-emergency complications, such as implant malpositions, are generally not covered, nor should they be."

Q: Given the rise of cosmetic surgery, do you, as an expert in the field, believe insurance companies may become more restrictive on coverage?
"Absolutely," says Dr. Plant. "Insurance companies and even public health care, such as the Canadian system, are always looking for ways to reduce expenditure, and if they find that complications of cosmetic procedures are becoming a significant expense they will start to specifically exclude those from coverage."

Dr. Shah thinks insurance companies are keeping an eye on cosmetic surgery and what sometimes follows. "I do believe that an insurance company will be more restrictive if it can prove that a complication arose from a cosmetic surgery procedure," he says.

"I think they already are very restrictive," says Dr. Doft. "It has become increasingly difficult to obtain pre-authorization for breast reduction surgeries — and these surgeries are medically necessary, not cosmetic. We find that it is unusual for an insurance company to approve surgeries without several telephone calls and often a peer-to-peer between the treating physician and the insurance company's physician."

Q: What questions should prospective patients ask their insurance company when considering elective surgery?
When seeking coverage, it makes sense to frame inquiries with a medical perspective. "When you pursue surgery from the standpoint of appearance, health insurers become very skeptical," says Moyer. "Getting your surgeon involved in making the coverage request can be helpful — an experienced doctor can paint a procedure in the best light for the insurance company to provide coverage."

Before proceeding, make sure you have a full understand of what your financial contribution to the procedure will be. "Ask what portion of the bill I will be responsible for and what my co-pay and deductible are," says Dr. Rowe.

Dr. Shah sees it differently: "Frankly, I would not recommend that patients alert their insurance companies to the fact that they are considering elective surgery. Elective surgery is a personal decision and not subject to the scrutiny of the health insurers. I believe that patients should attempt to be financially prepared in the event that a complication occurs and they end up bearing the financial responsibility."

If you do find yourself in a dispute, you can always get help from a lawyer who specializes in insurance law.

Mary Fetzer is a professional freelance writer and editor. She has 10 years of experience writing articles, blog posts, and press releases for online publications and has covered an enormous range of topics ranging from personal finance and international trade to pregnancy and senior living. Mary also writes about legal issues in everyday life on the Avvo Stories blog. Avvo provides free answers from lawyers, client reviews, and detailed profiles for 97 percent of all attorneys in the U.S. Follow them on Twitter and Facebook.