Will Insurance Cover My Cosmetic Surgery?

It is very common for people to come into my office and state, “My insurance company has told me that my tummy tuck operation will be covered.” Or they might have been told their eye lift or eye tuck operation will be covered because of blocked vision. The unfortunate truth is that the great majority of these cases are not covered by insurance companies, and the company is misrepresenting the truth. This article will cover some of the truths and facts about cosmetic surgery, plastic surgery, and insurance companies.I am a Board Certified Plastic Surgeon, and I (like most plastic surgeons) want insurance to work for my patients. It helps pay your expenses and is a great thing when covered! The plastic surgeon is on the side of the patient. It is very important to understand that the surgeon is on “your side.” We want the insurance to work or pay for the cosmetic surgery. My staff assists patients with all the paper work necessary for insurance claims. This includes appropriate codes, documents, and forms. Common requests are for tummy tuck surgery, eye lift or eye tuck surgery, and breast reduction surgery. Also, insurance coverage for a nose job or rhinoplasty is often desired. I want the procedures covered, but it is critical to know that it is not that simple, and most of the time it will not be covered.

The truth is the insurance company is not giving the patient the whole picture when they say a procedure is covered. They should tell you that most of the time these procedures are denied and are only approved infrequently. It can really disappoint a person, because they are told this by the insurance company, and then they don’t get approved. The patient then feels they were “robbed.” Insurance companies are in the business of making money. They do this by “denying” surgery which makes more company profit by saving the expense of surgery. It can not be over emphasized that they make money by denying your surgery! It might be listed as a covered procedure, but this rarely is the case. It disappoints the doctor too, because he then uses valuable consultation time talking about insurance issues, instead of your medical needs and surgery.

Family doctors or other physicians will often tell a patient that the surgery is covered. Patients come in saying, “My doc told me my surgery will be covered.” Unfortunately, the doctor who said this isn’t the one trying to get the insurance coverage. This can lead to disappointment when the surgery is ultimately denied.

Some examples will help with this discussion. These are true stories. The first is a women who had lost 70 pounds from diet and exercise. She was interested in a tummy tuck. She was concerned about hanging skin and rashing at the folded over skin. She called her insurance company as was told that this is a “covered benefit.” Photographs were submitted with all appropriate codes. Her case was unfortunately denied. The insurance company deemed it a cosmetic abdominoplasty. They said the skin would have to hang down half way to the knees to be covered. Fortunately, the patient was able to have the surgery on a cosmetic basis. She healed well and was extremely happy with her results.

Another example was a women who wanted her breasts lifted and reduced. She complained of breast pain, neck and back pain, and shoulder grooving from her bra. She wore a 40 DDD. She was 5′ 6″ tall and weighed 155 pounds. Photos were submitted and codes given for a breast reduction. Unfortunately, she was denied by her insurance company who said it was cosmetic breast surgery. They said she had to be close to ideal body weight (within 10%) and should lose 20 pounds and resubmit. Also, they said one pound of tissue would have to be removed per breast, if she was successful in the weight lose. This would leave her as a B cup and she wanted a C cup. She also proceeded with cosmetic breast surgery, without insurance. She wanted to pick her own size and not be forced to go too small. She ended up extremely happy with her new breasts, which were C cup and “perky!”It is intereting to understand how insurance companies really will fight to deny surgery. Patients might find it incredible that the companies considered cleft lip deformities in babies a cosmetic issue! Yes, this is true. We can thank our federal government who created a law stating cleft lip surgery is not cosmetic and mandated coverage. They forced the companies to accept that plastic surgery for cleft lip surgery is not cosmetic! If they were fighting this, you can bet they will fight tummy tuck or breast lift, or breast reduction surgery!

There are a few exceptions about cosmetic surgery and insurance coverage. If a person has had a gastric bypass then insurance coverage of the tummy tuck is easier, but it is not a guarantee. Also, rhinoplasty or nose job surgery and insurance companies can be a more positive experience. The septum or breathing aspect of the surgery can be covered. This is called a septoplasty. This is not the cosmetic aspect. However, the septum being approved can really offset the expenses of the surgery. Finally, eye lift surgery or blepharolasty surgery can be covered if a person fails the visual field test. This is a test that demonstrates major blocking of vision by hooding.This usually has to be severe however.It also is extremely difficult to get thigh lift surgery, buttock lift surgery, or lower body lift surgery covered, even after gastric bypass surgery and/or extreme weight loose. My office will try and fight for you, but you must remember it is difficult to win. They make money by denying surgery!!I am a board certified plastic surgeon who practices exclusively cosmetic surgery. Please check out the before and after photos on our web site. Also, please come in for a complimentary consultation to learn about your choices and options!