Americans spend billions of dollars on cosmetic procedures every year. Most patients pay out of pocket for such services; but while most plastic surgery procedures are not covered by health insurance, some treatments can be. According to the American Society of Plastic Surgeons (ASPS), some procedures are purely cosmetic and designated as elective surgeries; they will never be covered by insurance companies. However, medically necessary plastic surgery procedures are often included in insurance coverage policies.
So, what determines that a certain plastic surgery procedure is medically necessary and able to be covered by a health insurance plan? The American Medical Association (AMA) created an outline in the late 1980s for health insurance companies to help differentiate between elective cosmetic surgeries and necessary reconstructive surgeries; the AMA defines each so that insurance companies can determine whether coverage is appropriate.
HYPERLINK “https://policysearch.ama-assn.org/policyfinder/detail/cosmetic?uri=%2FAMADoc%2FHOD.xml-0-4326.xml” Definitions of “Cosmetic” and “Reconstructive” Surgery
Cosmetic Surgery: Performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem.
Reconstructive Surgery: Performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.
The bottom line is that most cosmetic procedures are not medically necessary, while most plastic surgery and reconstructive surgery procedures are deemed to be medically necessary. But many procedures have a dual purpose, which can complicate things. If a procedure is meant to treat an aesthetic issue as well as a functional health issue, the medical provider can have it documented as medically necessary. In cases like that, some health insurance companies might cover its cost.
There are many factors in determining whether a procedure is purely cosmetic or if it is reconstructive, as defined by the AMA. The exact standards can vary because not all health insurance companies have the same policies, but the ASPS recommends some specific criteria for assessing plastic surgery procedures to distinguish between cosmetic and reconstructive procedures. These criteria are key for providers to use for their explanations of their treatment, especially when it involves procedures that might have both an aesthetic purpose and a functional one.
To have a procedure officially documented as a medical necessity, a medical provider must make sure it qualifies according to specific criteria. But he or she also must validate that the surgery to be performed will address a functional health issue—that is, any concern(s) regarding the patient’s quality of life, related to the body part or health concern that is the focus of the procedure. The surgeon must assess the patient and submit both a written explanation and photographic evidence that points to a medical need to the insurance company, as well as providing proof that other non-surgical remedies have already been explored and/or tried.
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