INSURANCE COVERAGE INFORMATION FOR PATIENTS
The American Society of Plastic Surgeons has prepared the following information to assist you in better understanding your health insurance benefits for plastic surgery. It is intended to answer basic questions and guide you in communicating effectively with office staff at the Plastic Surgeons of the Hudson Valley and your health insurance carrier. It won’t answer all of your questions because a lot depends on your individual circumstances and your insurance. Be sure to contact your insurance company if you have any questions about coverage for specific services. Not all plans cover all services.
About Plastic Surgery
There are two kinds of plastic surgery: reconstructive surgery and cosmetic surgery.
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.
Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem.
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 your 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.
Reconstructive surgery is generally covered by most health insurance policies, although coverage for specific procedures and levels of coverage vary greatly among insurance companies. If your plastic surgeon does not have a contract with your insurance company (non-participating), you are responsible for any amount not covered by your plan.
Cosmetic surgery, however, is not covered by health insurance because it is elective. Cosmetic surgery is a choice and not considered a medical necessity. Your surgical fee will depend on the operating time involved and the surgical technique used. At the time of your consultation the patient coordinator will provide you with an individual quote.
There are a number of “gray areas” in coverage for plastic surgery that sometimes require special consideration by an insurance carrier. There areas usually involve surgical operations which may be reconstructive or cosmetic, depending on the 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/septoplasty) may be covered if it will correct a defect that causes breathing difficulties.
In assessing whether the procedure will be covered by your insurance contract, the insurance company 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. Prior authorization and/or approval are not guarantees of payment by your insurance company. Our office will work with you and your insurance company to help to facilitate coverage and assist you in determining your costs.
Understanding your specific insurance policy and your responsibility for payment is essential.
Our Poughkeepsie plastic surgeons practice in an ethical manner and will submit claims to insurance carriers only for valid reconstructive plastic surgery. Any attempt to misrepresent a cosmetic procedure as reconstructive is unethical.