Cosmetic surgery has gained significant popularity over the years. Many people choose cosmetic surgery for aesthetic reasons, while others may undergo procedures to correct physical abnormalities or enhance their appearance. However, one of the most frequently asked questions of prospective patients is: Does insurance cover cosmetic surgery?

While many individuals hope that insurance providers will cover the cost of cosmetic procedures, the reality is often more complex. Whether or not a cosmetic surgery procedure is covered by insurance depends on several factors, including whether the surgery is deemed medically necessary or elective, the specific insurance policy, and the nature of the procedure itself. In this blog, we will explore the various aspects of insurance coverage for plastic surgery procedures, distinguish between reconstructive and cosmetic surgeries, and provide insight into determining whether your insurance provider might cover a particular procedure.

What Is Cosmetic Surgery?

Cosmetic surgery is procedures to improve or alter a person’s physical appearance. Unlike reconstructive surgery, which is typically performed to correct functional impairments or abnormalities caused by accidents, illnesses, or congenital defects, cosmetic surgery is generally performed for aesthetic purposes.

Some common cosmetic surgery procedures include:

• Rhinoplasty (nose job)
• Breast augmentation or breast reduction
• Liposuction
• Tummy tuck (abdominoplasty)
• Facelifts
• Eyelid surgery (blepharoplasty)
• Botox injections and dermal fillers (non-surgical cosmetic treatments)

These procedures are often elective, meaning they are not essential for the patient’s health or well-being but are desired for aesthetic reasons. This is a key distinction when considering whether health insurance providers will cover the procedure.

What Is Reconstructive Surgery?

Reconstructive surgery refers to procedures performed to restore the normal appearance or function of a body part affected by trauma, disease, or congenital abnormalities. This type of surgery is often medically necessary, meaning it corrects a physical or functional issue rather than for purely aesthetic reasons.

Common reconstructive surgery procedures include:

• Breast reconstruction after breast cancer
• Cleft lip and palate surgery
• Burn repair surgery
• Reconstructive surgery following traumatic injuries

Because reconstructive surgery addresses functional impairment or physical abnormalities, it is more likely to be covered by insurance policies than cosmetic surgery.

Does Insurance Cover Cosmetic Surgery?

The short answer is no, most health insurance providers do not cover the cost of cosmetic surgery unless it is deemed medically necessary. However, the distinction between cosmetic and medically necessary surgery is often a gray area, and each case is assessed individually. Let’s break down the factors that influence whether or not insurance will cover plastic surgery:

1. Medical Necessity vs. Aesthetic Enhancement

The most significant factor in determining whether a cosmetic procedure is covered by insurance is whether it is considered medically necessary. If the procedure is required to address a functional issue, such as a deviated septum (which can affect breathing) or breast reconstruction following breast cancer treatment, insurance is more likely to cover the costs.

For example:

• Rhinoplasty (nose job) performed to correct breathing difficulties caused by a deviated septum may be considered medically necessary, and insurance may cover the procedure.
• Breast reduction surgery to alleviate back pain caused by large breasts may be covered if it is deemed necessary for improving the patient’s quality of life and relieving pain. However, if the procedure is purely for aesthetic reasons, such as making the breasts smaller for personal preference, it is unlikely to be covered by insurance.
• Breast reconstruction following a mastectomy due to breast cancer is often considered medically necessary and is typically covered by insurance, as it restores both appearance and function.

Conversely, purely cosmetic procedures, such as facelifts, tummy tucks, and liposuction, are typically not covered because they are performed for aesthetic reasons rather than medical necessity.

2. Insurance Policy and Provider

The specific details of your insurance policy will determine whether your cosmetic procedure is covered. Insurance carriers often vary in coverage options, so it’s essential to review the terms of your policy or contact your insurance provider directly for clarification.

Some insurance policies may provide coverage for procedures that have both cosmetic and functional components. For example:

• Dental surgery for oral health might be partially covered, while cosmetic dental treatments (teeth whitening or veneers) are often excluded.
• Plastic surgery procedures that correct structural abnormalities and offer aesthetic improvement may be covered if a clear medical necessity is demonstrated.

3. Prior Authorization and Documentation

In many cases, prior authorization from your insurance company may be required before plastic surgery. This is especially true for procedures that are borderline between medically necessary and cosmetic. Your surgeon or plastic surgeon must provide detailed records and medical documentation explaining why the procedure is necessary for your health and well-being.

For example, suppose you’re having rhinoplasty to improve breathing. In that case, your surgeon will likely need to submit information to demonstrate that your deviated septum is impairing your breathing and causing health issues like sleep apnea or frequent sinus infections. Similarly, if you’re undergoing breast reconstruction, your plastic surgeon will need to document the medical necessity following your mastectomy.

4. Elective vs. Non-Elective Surgery

Most cosmetic surgery procedures are considered elective, meaning the patient chooses them for aesthetic reasons and are not required for medical purposes. Elective surgery is generally not covered by insurance. However, there are some exceptions for cosmetic procedures that address both functional impairments and cosmetic concerns. For instance:

• Cosmetic surgery to remove excess skin after significant weight loss may be partially covered by insurance if it causes functional problems such as chafing or rashes.
• Nose jobs to correct cosmetic and breathing problems may be eligible for coverage if the medical necessity can be demonstrated.

5. Financing Options

Even if your insurance company does not cover cosmetic surgery, many plastic surgeons offer flexible financing options to help patients pay for elective procedures. This can include payment plans, medical loans, or care credit options that allow you to spread out the cost of surgery over time.

6. Consultation with Board Certified Plastic Surgeons

To ensure that you receive the best care and clear guidance on what is and is not covered, it’s important to consult with an experienced, board-certified plastic surgeon. A certified surgeon will provide an initial consultation to assess your cosmetic concerns and determine whether the procedure is medically necessary or purely cosmetic. They can also guide you through the insurance process, help with prior authorization, and assist in submitting the necessary documentation to support your case.

7. Cosmetic Surgery Procedures That Are Often Not Covered

Some common cosmetic surgery procedures that are typically not covered by insurance include:

• Facelifts or neck lifts for aesthetic purposes
• Liposuction for body contouring
• Breast augmentation (unless it’s performed for reconstruction after cancer)
• Tummy tucks (unless performed to repair diastasis recti after pregnancy or weight loss)
• Botox or dermal fillers (non-surgical cosmetic treatments)
• Rhinoplasty for purely cosmetic reasons

These procedures are often classified as elective surgeries, meaning they are performed to enhance the patient’s appearance rather than address any underlying medical issue.

Conclusion

While many cosmetic surgery procedures are not covered by health insurance, there are exceptions, particularly when the procedure is deemed medically necessary. Reconstructive surgery, such as breast reconstruction following breast cancer, or rhinoplasty to correct breathing problems due to a deviated septum, is typically covered by insurance. Cosmetic procedures that are purely aesthetic, such as facelifts, liposuction, and breast augmentation, are usually excluded from coverage.

Understanding your insurance coverage is essential before undergoing any plastic surgery procedure. Review your insurance policy, consult a board-certified plastic surgeon, and discuss all financing options to ensure you are well informed about your treatment costs.

If you’re considering cosmetic surgery, remember that while insurance coverage may not always apply, the right surgeon and a clear understanding of your medical necessity can help you navigate the process more easily.

References

https://www.plasticsurgery.org/cosmetic-procedures

https://www.mayoclinic.org/tests-procedures/cosmetic-surgery/about/pac-20385138

https://my.clevelandclinic.org/health/procedures/11007-cosmetic-surgery