Cosmetic Plastic Surgery: Patient Insurance Guide

As you plan for plastic surgery, you will probably learn a lot about what will happen in the operating room and discuss with your plastic surgeon how you will look and feel afterward. However, another important part of being an informed patient is knowing about the costs associated with surgery, and how these costs will be paid.

The American Society of Plastic Surgeons (ASPS) has prepared this information to assist you in better understanding health insurance benefits for plastic surgery. It is intended to answer basic questions and guide you in communicating effectively with your plastic surgeon's office staff and your insurance carrier. It won't answer all of your questions, because a lot depends on individual circumstances and your own insurance. Be sure to contact your insurance company or your employer's Human Resources/Benefits department with any questions you have about coverage for specific services.

About Plastic Surgery

Derived from the Greek word "plastikos," meaning to mold or give form, the specialty of plastic surgery encompasses two general categories:

• Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.*
• Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.*

*Definitions as adopted by the American Medical Association and the American Society of Plastic Surgeons (ASPS).

What's Covered

Your insurance policy is an agreement between you and your insurance company. In contrast, an agreement on services and fees is an agreement between you and your plastic surgeon. When you have surgery, you become responsible for payment of the doctor's fees. Coverage for services and levels of payment by your insurance company depend on the terms of the contract between you and your insurance company. You are responsible for any amounts not covered by your plan.
Reconstructive surgery is generally covered by most health insurance policies, although coverage for specific procedures and levels of coverage may vary greatly.

Cosmetic surgery, however, is usually not covered by health insurance because it is elective. Cosmetic surgery is your choice and not considered a medical necessity.

There are a number of "gray areas" in coverage for plastic surgery that sometimes require special consideration by an insurance carrier. These areas usually involve surgical operations which may be reconstructive or cosmetic, depending on each patient's situation. For example, eyelid surgery (blepharoplasty) - a procedure normally performed to achieve cosmetic improvement - may be covered if the eyelids are drooping severely and obscuring a patient's vision. Or, nose surgery (rhinoplasty and/or septoplasty) may be covered if it will correct a defect that causes breathing difficulties.

In assessing whether the procedure will be covered by the patient's insurance contract, the carrier looks at the primary reason the procedure is being performed: is it for relief of symptoms or for cosmetic improvement? If a procedure is within these "gray areas," insurance companies often require prior authorization or approval before the surgery is performed and/or extra documentation after surgery to determine how much of the cost of your care they will cover.

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