Plastic surgery insurance coverage

This information to help you in better understanding health insurance benefits for plastic surgery. It is intended to answer basic questions and guide you in communicating effectively with your plastic surgeon's office staff and your insurance carrier. It won't answer all of your questions, because a lot depends on individual circumstances and your own insurance. Be sure to contact your insurance company or your employer's Human Resources/Benefits department with any questions you have about coverage for specific services.

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 the 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. You are responsible for any amounts not covered by your plan.

Cosmetic surgery, however, is usually not covered by health insurance because it is elective. Cosmetic surgery is your choice and not considered a medical necessity.

There are a number of "gray areas" in coverage for plastic surgery that sometimes require special consideration by an insurance carrier. These areas usually involve surgical operations which may be reconstructive or cosmetic, depending on each patient's situation.

Example of "gray areas" in coverage is 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 and/or septoplasty) may be covered if it will correct a defect that causes breathing difficulties.

It's important to understand what's included in your policy before you advance too far in planning surgery. Some policies provide coverage for many plastic surgery procedures while others are more limited in coverage. Read your policy and benefits manual carefully and discuss any questions you may have with your insurance plan manager.

Typical cost sharing option maybe a deductible, is the total amount of covered medical expenses that must be paid by the patient before the insurance company begins paying benefits. Examples of standard deductibles are $100, $250, or $500. After this requirement is reached, the insurer will begin paying according to terms of the contract-often 75%-85% - of covered medical costs. The patient is responsible for any remaining balance.

Your benefits administrator will be able to explain these points to you. Be certain that all patient financial responsibilities are understood before having surgery. If you can calculate your costs based on the terms of your insurance plan, there will be no misunderstanding later of your obligation.

The amount billed to your insurance by your physician may not be the actual amount on which reimbursement is calculated; your insurance plan may assign a lesser fee for the procedure. Your particular situation will reflect the coverage and cost-sharing agreement of your insurance plan; the deductible and any amount of the deductible that you have already met; and any dual coverage available if you are also carried on your spouse's or another secondary plan.

When you visit your plastic surgeon's office for the first time, bring your insurance card with you. If you are eligible for coverage under another plan, bring this insurance card with you as well. With verification of this information on file, the plastic surgeon's office staff may bill your health care plan directly for covered services.

Once you and your plastic surgeon have agreed on the specifics of your care and the fees, it's likely that your plastic surgeon will assist in determining if your care is indeed covered by your insurance plan. Your plastic surgeon will probably send a pre-authorization letter to your insurance carrier, explaining the procedure, listing the ICD-9 (diagnosis) and CPT (procedure) codes, the surgical fee, place of service, and anesthesia. The pre-authorization letter will request authorization to proceed with your surgery and an indication of the level of coverage provided by your policy. Before giving the "go-ahead" to proceed with surgery, the insurance company will review your case to ensure that the procedure is medically necessary based on the insurance carrier's guidelines of medical necessity.

Keep accurate notes of all communication with the insurance company and your plastic surgeon, and make a personal file to keep copies of completed insurance forms and every letter sent or received. Keep your file in a safe place in case papers are lost in the insurance process or the mail or you need to reference anything about your surgery.

If your insurance company does not authorize payment for your reconstructive surgery, or if it agrees to pay only a small percentage of a claim, you may choose to appeal the decision.

Your appeal letter should also request a full explanation of why coverage is being denied or paid at a reduced level. Request that the claims supervisor send you a copy of the specific statement - drawn from the policy or from the benefits booklet - that explains why your coverage is limited or denied. Attach a copy of the denial notification and a copy of your doctor's pre-authorization letter to again provide the statement of your surgeon's fee, the applicable billing codes. Position papers are available from your plastic surgeon.

Some plastic surgeons accept major credit cards or offer financing programs that allow patients to make manageable monthly payments for cosmetic surgery. Ask your surgeon's office staff if any such programs are available.