Insurance policies differ on reconstructive surgeries not covered by insurance. The majority of insurance companies abide by definitions provided by the American Medical Association and the American Society of Plastic Surgery.
About Reconstructive Surgery Not Covered By Insurance
Reconstructive surgery not covered by insurance varies from one insurance policy to another. In fact, coverage for both plastic surgery and reconstructive procedures varies depending on your health insurance plan. The basic difference is that reconstructive surgery is carried out to repair abnormal body structures that result from congenital defects, developmental abnormalities, trauma, infection, tumors or disease.
Reconstructive surgery is generally performed to improve function. However, reconstructive surgery may also be done to establish a more normal appearance. This fine line between elective cosmetic surgery and reconstructive surgery is where coverage disputes sometimes arise because cosmetic surgery reshapes normal structures of the body in order to improve a patient's physical appearance and self-esteem. The difference is that reconstructive surgery is done to correct abnormal body structures.
In most cases, if there's a medical reason for the surgery, it will be covered. A good example is a functional rhinoplasty, which is performed on patients with a severe nasal obstruction. This surgery improves the patient's quality of life. In another case, a patient may want a rhinoplasty because they feel their nose is unattractive. Although the second patient would perceive a need, the first patient may have it covered by insurance because the need is functional while the second patient's reason is aesthetic.
Sometimes the thought that reconstructive surgeries not covered by insurance may seem unfair, but most insurance companies use medical criteria to determine if surgery should be covered. Surgeries requested as reconstructional, but commonly performed for cosmetic purposes must provide medical reasons to be covered. Surgeries such as the following fall into question:
- Breast reduction - medical reasons are based on height, weight, and medical conditions. For this surgery a set number of grams must be removed from each breast.
- Functional rhinoplasty - severe nasal obstruction
- Facial reconstructive surgery -- surgery to repair damage from injury, cancer, or disease
- Otoplasty - when used to create ears for those born without them or who lost them due to injury
To find out which reconstructive surgeries are not covered by insurance you should read your insurance policy. You may also call your insurance provider with questions and have them explain what is needed in plain terms. Understanding a Health Policy can be difficult. If you don't understand what they tell you, ask for clarification.
Ask your physician to assist you in providing necessary information to the insurance company. Be sure to provide your insurance card to your physician's office so they can assist with the preauthorization as well as billing your company for your visit.
The insurance company will look over the request and notify you as to what will be covered. Other factors that affect coverage are co-payments and deductibles. All of these factors will be outlined in your insurance contract. Once you receive authorization along with the amount that would be covered, don't hesitate to call the insurance company if you have questions. Be clear on:
- Physician charges
- Hospital, clinic or other facility charges
- Pathology charges (if tissue is removed)
- Anesthesia costs
It's best to be clear on the amount you may owe. Have your insurance provider explain the benefits you've already used, what deductible you would have to pay and any other benefits that may apply to time off work or follow-up visits to your physician.
When Your Request is Denied
It is not uncommon for a request for reconstructive surgery to be denied. If this happens to you, don't give up. Instead proceed with an appeal to your provider.
- Be sure your policy does not exclude coverage for the procedure
- Ask your surgeon to write a letter asking your insurer to reconsider
- Ask your insurance provider to outline from your policy the reason your request was denied
- Ask a second board-certified plastic surgeon to review your case and send a copy of his findings to your insurance commissioner
Keep a file of all your correspondence and a log of phone calls along with names of the people you speak to. When it comes to reconstructive surgery, only your insurance company can tell you if the procedure you need will be covered or not.