United States consumers spend an estimated $16.5 billion on cosmetic plastic surgery and minimally invasive procedures in 2018, according to a report by the American Society of Plastic Surgeons. How much was covered by insurance is a much more nebulous number to determine. Insurance companies naturally want to keep control of what they end up paying out and so they develop criteria to define what they will cover and what they won’t. Let’s look at those factors more closely.
Is a Plastic Surgery Procedure Necessary or Not?
An insurance company will always want to answer three questions to determine eligibility.
- Does the surgery restore a necessary body function or help maintain quality of life?
- Is the surgery intended to repair or reconstruct a part of the body that was damaged?
- Is the surgery solely cosmetic?
Both the American Medical Association (AMA) and the American Society of Plastic Surgeons (ASPS) have established guidelines that define what is considered medically necessary. Insurance companies tend to follow these guidelines, but your mileage may vary. Each insurance company has its own rules and policies, so it is up to the patient to do their research when choosing a medical insurance policy.
Guidelines for “Medically Necessary” Procedures
The definitions of “medically necessary” generally revolve around repairing a naturally occurring defect or damage caused by trauma or the effects of severe disease. One example is having eyelids reduced to restore vision that has diminished over time due to the patient’s eyelids sagging. Although this can improve how a patient looks, the underlying reason for the surgery is a practical one. It restores quality of life.
A surgical procedure will tend to be defined as a “cosmetic plastic surgery procedure” when its primary purpose to make the patient more attractive. The ASPS writes this on their site:
“Cosmetic plastic surgery includes surgical and nonsurgical procedures that
enhance and reshape structures of the body to improve appearance and confidence.”
The problem with this broad definition is in how an insurance company interprets that guidance. So, when in doubt, find out. Get a definitive answer from your insurance company to avoid unpleasant surprises later. Here is a list of procedures that will most likely not be covered:
- Breast Augmentation
- Breast Lift
- Nonsurgical Fat Reduction
- Many Types of Lifts
- Botox®, Dysport®, Xeomin®, Jeuveau® Chemical Peel
- Most other non-invasive cosmetic procedures
Again, it is essential to get the final answer from your insurance provider. Thorough research beforehand will prevent a lot of stress later.