While it may seem obvious that reconstructive plastic surgery procedures are covered by insurance and cosmetic plastic surgery procedures are not covered, there are some nuances that necessitate clarification. Even the Australian government’s national health service weighed in on the debate recently.
What’s covered?
Essentially, if you have a deformity on your body that you were born with or you acquired after trauma or cancer, these types of things are clearly covered. For example, a cleft lip or palate or other congenital abnormality will be covered by insurance. If you have an open wound on your leg that needs to be covered by a skin graft after a car accident, that will be covered. If you had breast cancer and need breast reconstruction after the breast is removed, that is covered by insurance. Those are the “easy” ones when determining what’s covered by insurance or not.
What may not be covered?
The procedures that may need a few letters written to the insurance company or a few other hoops to jump through before they’re covered, are breast reduction surgery or a panniculectomy. If you can prove, either from a physical therapist or multiple examinations that your breasts are so heavy that they cause you neck and back pain, a breast reduction may be covered by insurance.
If you have excess skin hanging from your lower abdomen, this is referred to as a panniculus. You may need to have photos showing infection under the skin before insurance will pay to have the skin removed, in a procedure called a panniculectomy. But this should not be confused with a tummy tuck. A tummy tuck also includes removal of excess hanging skin, a shift of the navel to match the new contours of your abdomen, along with tightening of the abdominal wall and liposuction. None of these additional procedures are included in a panniculectomy. Be sure you know what operation you’re getting because your hopes may be dashed if you don’t have the appropriate expectations.
Don’t forget that even if your procedure is considered medically necessary, you may have a high deductible health plan, meaning you’ll be paying out of pocket for a procedure as though it is a cosmetic procedure, before your insurance benefits kick in. If you are in need of a procedure that is cosmetic or haven’t met your deductible, and want to know the cost out-of-pocket, click here.
