Plastic surgery. We’ve all heard this term flung around in tabloids, citing the latest celebrity “before and afters.” However, most people don’t realize that it includes both reconstructive and cosmetic procedures.
While there’s an overlap, these kinds of surgeries serve entirely different purposes. We’ll explain the distinctions, how it affects health insurance, and more, below.
As its name suggests, procedures under this category restore normal appearance and function after trauma, congenital disabilities, disorders, infections, or even diseases like cancer.
Reconstructive or functional surgery aims to correct conditions that impair your physical capabilities. That’s why it’s generally considered a medical necessity.
However, there’s usually an aesthetic element, because most of these health issues affect the way you look, too. People undergo reconstructive procedures for a plethora of reasons. Some examples include:
As long as it’s correcting a medical condition or restoring function, then insurance will often pay for surgery under this category. Nonetheless, it’s prudent to do your research beforehand.
You’ll have to prove that a procedure addresses function, improves the quality of life, and is medically necessary. Still, private health insurance coverage varies, as do the requirements. That’s why it’s vital to discuss it directly with your provider first.
Cosmetic surgery focuses entirely on enhancing appearance and does not focus on reconstruction or restoration of function. Popular amongst the rich and famous, these procedures are done for purely aesthetic reasons.
Most of us have an aspect of our appearance that we don’t particularly like. However, when a physical feature adversely affects self-esteem, many people opt for cosmetic surgery.
It’s used to improve symmetry, reshape existing structure, or adjust proportion. From facelifts and rhinoplasties to breast augmentation and liposuction, there are various types of cosmetic procedures. Other kinds include:
Because it’s an elective surgery that doesn’t treat a medical condition, insurance won’t cover the costs. You’ll have to pay out of pocket, which can become steep. For example, rhinoplasty (a nose job) will set you back between $9,000 to $20,000.
However, for some, this is a small price to pay when it comes to boosting their body image and permanently increasing their confidence.
While the above two surgeries are entirely different, there are cases where they tend to overlap. This creates a gray area that could affect your pocket.
For instance, breast reductions are highly-debatable. As a cosmetic procedure, it could be regarded as reconstructive for medical reasons. If it alleviates severe pain and back problems, then it’ll usually fulfill the “necessity” requirement.
Another controversial surgery is rhinoplasty. In some cases, issues with the nose, such as a deviated septum can cause difficulty breathing. Insurance will cover the breathing aspect of the surgery, but they will refuse coverage of the aesthetic part of the surgery.
Eyelid surgery presents the same argument. Many people have this procedure to get rid of loose, sagging, or droopy skin around the eyes. Even so, it becomes a medical condition that needs treatment if it impairs vision.
Before going under the knife for any reason, it’s best to consult your doctor and your insurance provider.
Not all types of surgeries are covered. If you want to get insurance to pay for a procedure, it’s worth doing your homework first. Here are a few factors to consider:
First, find out the extent of your coverage, so that a doctor can advise on the available options. Some insurance plans exclude certain procedures, even if it is medically necessary. Also, keep in mind copayments, whether they apply, and what the amount is.
According to the American Society of Plastic Surgeons and the American Academy of Facial Plastic and Reconstructive Surgery guidelines, the medical necessity of a procedure needs to be proven.
You can do this by providing photographic or other documented evidence. It should also be established that you’ve already tried other non-surgical or non-procedure alternatives. Your surgeon can help figure this out.
Now, all you need to do is take the evidence and information to a doctor for a referral.
Next, consult a specialist. Most surgeons are well-versed in working with insurance companies; they’ll help you understand the options clearly.
There are various distinctions between reconstructive and cosmetic surgery. Generally, the former treats medical conditions, while the latter is for aesthetic purposes.
However, some areas overlap, so it’s wise to do some research before considering a procedure. By knowing the health insurance factors, you’ll determine the limitation of coverage.
Prove the medical necessity before getting a referral, and a surgeon will help you sift through the differences.
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