Is A Cosmetic Procedure Ever Covered By Insurance?

According to the American Society of Plastic Surgeons (ASPS), Americans spent some $16.5 million on cosmetic surgery and minimally invasive procedures in 2018 alone, and it is safe to say a good portion of that figure was an out-of-pocket expenditure for patients. With national cost averages ranging from $3,800 for a breast augmentation to upwards of $8,000 for a facelift, cosmetic surgery is no small expense and most treatments (surgical or otherwise) are not covered by health insurance.

That's not to say there aren’t exceptions to the rule. While elective procedures that are purely cosmetic in nature will always operate (pun intended) outside the realm of insurance companies, plastic surgery procedures that can be classified as 'medically necessary' are often part of insurance policies.

So, what makes an invasive or non-invasive procedure medically necessary and, therefore, covered by a health insurance plan? The AEDITION breaks it down.

What Makes a Procedure 'Medically Necessary'

In June 1989, the American Medical Association (AMA) adopted the following definitions of ‘cosmetic surgery’ and ‘reconstructive surgery’ that are used by health insurance companies to determine coverage.

• Cosmetic Surgery: Performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem.
• Reconstructive Surgery: Performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.

In theory, the definitions are black and white: cosmetic procedures are not medically necessary; plastic and reconstructive surgery procedures are. In reality, there is quite a bit of gray area. Many procedures have a dual purpose that treats both an aesthetic concern and a functional health problem. If the provider can document the medically necessary component of the procedure and any non-surgical remediation that was previously taken to correct the health issue, Medicare or private insurance may very well cover the cost.

What Procedures May Be Covered By Insurance

In order to successfully document the medical necessity of a procedure, providers must prove the surgery the patient is interested in directly addresses the quality of life concern(s) surrounding the body part or health problem in question. This process involves:

1. Submitting photographic evidence (not just a written explanation) to the insurance company
2. Proving non-surgical or non-procedure remedies have already been explored

While the exact standards may vary by insurance company, the ASPS offers a recommended criteria for distinguishing between a cosmetic surgery procedure and a plastic or reconstructive surgery that providers can use when explaining treatments that have a dual aesthetic and functional purpose. But what does that mean in layman's terms? Below is a guide to surgical and non-surgical procedures that sometimes qualify for insurance coverage.

Abdominoplasty (a.k.a Tummy Tuck) & Panniculectomy

Weight loss procedures (think: gastric sleeves, lap gastric bands, and gastric bypass) are often covered by insurance for patients who have a high body mass index (BMI) coupled with comorbidities like heart disease or type 2 diabetes. In the aftermath of a major weight loss, there are a few cosmetic surgeries that may be considered functional procedures in order to improve a patient's quality of life:

• Abdominoplasty: A tummy tuck typically combines fat removal (i.e. liposuction) with skin removal and/or tightening, which may be required by patients in the aftermath of losing a significant amount of weight.
• Panniculectomy: The surgical procedure removes excess skin on patients who have lost a significant amount of weight (naturally or via a bariatric procedure).

While insurance coverage of a panniculectomy or tummy tuck is not as common as weight loss surgery, they may be deemed medically necessary if a patient is in pain, unable to participate in normal activities, or at risk of developing a skin condition.

Blepharoplasty (a.k.a. Eyelid Surgery)

Aging eyelids don't just cause cosmetic concerns, drooping eyelids have the ability to impair vision. For patients who are dealing with poor eyesight as a result of sagging skin around the eyes, an upper eyelid blepharoplasty may be deemed medically necessary to correct the problem. During the surgery, a plastic or oculoplastic surgeon will remove excess skin to lift and open the eye. While many insurance policies will cover the functional component of the surgery, additional cosmetic improvements may need to be paid for out of pocket. It should also be noted that lower eyelid blepharoplasty is more difficult to classify as a functional procedure.

Botox®

No, neurotoxin injections to get rid of fine lines and wrinkles are not going to be covered by your insurance company, but there are therapeutic uses for Botox® that may be. In 2010, Botox® was approved by the U.S. Food and Drug Administration (FDA) to treat chronic migraine in patients over the age of 18. When injected around the pain fibers that are involved in headaches, Botox® blocks the release of chemicals involved in pain transmission. The FDA-recommended dosage is 155 units (administered every 10 to 12 weeks) for migraine patients, and the treatment is covered by most insurance plans (including Medicare and Medicaid).

Breast Surgery

As you can probably guess, a breast augmentation to cosmetically enhance the size or shape of the chest isn't going to be covered by health insurance plans, but certain kinds of breast surgery can be considered medically necessary:

• Post-Mastectomy Breast Reconstruction: As per the 1998 Women’s Health and Cancer Rights Act (WHCRA), group health plans that cover mastectomy (be it for breast cancer prevention or treatment) must also cover breast reconstruction — in the form of prostheses (like breast implants) — and other procedures for both breasts. In such cases, providers do not need to document health problems or trials of alternative treatment. Medicare also covers bilateral breast reconstruction in post-mastectomy patients.
• Reduction Mammoplasty (a.k.a. Breast Reduction): Women with symptomatic macromastia (large breasts) may deal with neck, nerve, shoulder, and back pain, breast discomfort, an inability to engage in certain activities, and/or dermatitis or rashes beneath the breasts secondary to the condition. In such cases, a breast reduction surgery may be covered by insurance after six to 12 months (on average) of documentation is presented to show alternative treatments (think: visits to a physical therapist, chiropractor, or orthopedist) were unsuccessful.

It should be noted that gynecomastia surgery (a.k.a. male breast reduction) is much more difficult to classify as a functional procedure than reduction mammoplasty for women — though the ASPS has compiled a set of guidelines that encompasses pain and discomfort, suspected malignancy, and more and can be used for evaluating insurance coverage for both adolescents and adults.

Otoplasty (a.k.a. Ear Surgery)

Otoplasty can be used to improve or correct the shape, proportion, and/or position of the ear. Such surgical procedures are performed in children and adults alike, and an ear surgery may be covered by health insurance if a provider is able to provide one of the following:

1. Document a medical problem (like hearing loss) caused by abnormal shaped ears
2. Document that the ear deformity is from a congenital abnormality

Unlike other procedures that require doctors also show the patient participated in a trial of alternative treatments, patients with a congenital abnormality of the ear do not need to first experiment with non-surgical remedies.

Rhinoplasty (a.k.a Nose Job)

Just as you probably have a friend who 'wanted' a nose job, you likely know someone who 'needed' a rhinoplasty. Difficulty breathing, nose bleeds, and sinus problems are just a few of the health concerns that can lead a patient to need nose surgery. After proving that non-invasive alternatives (like nasal spray) are ineffective, insurance may cover some or all of the procedure.

Medically speaking, the surgical procedure that corrects a deviated septum (one common cause of breathing issues) is known as a septoplasty and only addresses the inner workings of the nose. This procedure, which is almost always covered by insurance, has no bearing on the appearance of the nose. In some cases, a rhinoplasty that improves the shape or aesthetic of the external nose structure can be deemed medically necessary. Otherwise, patients who wish to make cosmetic changes (in addition to the functional improvements) may need to pay for that portion out of pocket.

The Takeaway

Needless to say, there are many subtle intricacies that determine whether a procedure is deemed ‘cosmetic’ or ‘plastic and reconstructive.’ That distinction, however, plays a direct role in why it may or may not be covered by insurance. Consulting with a board certified plastic surgeon will provide clarity on whether your preferred surgical procedure could qualify for insurance coverage in accordance with your health plan.