TriHealth Surgical Care

Reconstructive Plastic Surgery: What's Covered

Insurance: What's Covered

Though Cosmetic surgery is usually not covered by your health insurance because it is not considered “medically necessary, Reconstructive surgery is generally covered by most health insurance policies, although coverage for specific procedures and the levels of coverage may vary greatly.

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. 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 and/or septoplasty) may be covered if it will correct a defect that causes breathing difficulties.

In considering whether the procedure will be covered by the 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 only? 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.

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. It is important to note that even If a procedure is listed as “covered” in your policy description, it still requires an evaluation and ultimately you may be required to fit specific criteria for that benefit to actually be covered.