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Does insurance actually cover cosmetic surgery?

Cosmetic surgery isn’t going anywhere.

TIME magazine’s recent cover story, “Nip, Tuck or Else” highlights just how mainstream a little work with a needle and scalpel has truly become.

Many questions come to mind when considering invasive plastic surgery — even injectables! For instance, what happens if elective surgery creates a medical emergency? Will your insurance pay? Which surprising procedures are covered by insurance, and which might you find hard to believe insurers won’t pick up the tab for? Finally, how can you protect yourself from cosmetic surgery snafus?

Consider this your beginner’s guide to navigating the oftentimes convoluted world of cosmetic surgery.

Which procedures does your insurance cover now — and what are some surprising health surgeries that aren’t?

Breast reduction, lift and implants might be covered by insurance if there’s a reconstructive need or debilitating back pain, explains Dr. Michelle Zweifler, board-certified plastic surgeon and adviser.

“If a woman has been suffering with back, neck and shoulder pain, rashes and numbness, there’s a case for having it covered, but they would have to exhaust other conservative therapies such as chiropractic care, three to six months of physical therapy and prescription pain meds,” she adds.

If it can be argued that it’s impeding or impairing vision, eyelid surgery that removes excess skin interfering with peripheral vision can be covered in full by insurance. As far as rhinoplasties, “Only if there’s a severe functional impairment, for instance, the patient can’t breathe normally,” says board-certified plastic surgeon Dr. Jennifer Walden.

Could a trip to the neurologist score you free Botox? Perhaps! Neurologists can administer the botulinum toxin and will typically deal with the paperwork to submit it to insurance. There must be a medical need, though. Sorry, ladies and gents!

On the other hand, cysts, moles and benign tumor removals might not be covered by insurance. Medicare may pay for biopsies of cysts, but not their removal and they may begin to cause discomfort over time. According to the CDC, one out of every two American adults aged 30 and over has periodontal disease, and dental work to correct a receding gum line is also not covered by general insurance.

What about gender reassignment surgery?

Governor Andrew Cuomo has cleared gender reassignment surgery in New York City, as reported in The New York Times. “State law requires insurance coverage for the diagnosis and treatment of psychological disorders, people who are found to have a mismatch between their birth sex and their internal sense of gender are entitled to insurance coverage for treatments related to that condition, called gender dysphoria.” Other states covering gender reassignment include California, Colorado, Connecticut, Illinois, Massachusetts, Oregon, Vermont and Washington.

Are botched procedures covered if it creates a medical emergency?

Thankfully, most experts and plastic surgeons we’ve spoken with say yes. If you develop an infection or are dealing with excessive bleeding or other complications that land you in the hospital, most insurance plans will cover it. It becomes categorized as a “medical code” instead of a “cosmetic code” when entered into the system. Dr. Zweifler advises checking ahead of time with your insurance company.

Are off-label procedure snafus covered?

Botox has been used off-label for migraines and hyperhidrosis, but what happens if you develop a reaction to this or any other injectable? “Off-label snafus are not covered,” explains Dr. Walden. If that injectable approved for tear-troughs made your cheeks look like a puffer fish — tough luck. You’ll be picking up the cost of any follow ups to remedy.

What if it becomes more than just a little swelling, but instead a life-threatening problem? Dr. Zweifler adds, “Each insurance plan is different, but most may cover treating the larger medical problem such as bleeding and infection, and in this even most plastic surgeons refer patients straight to the emergency room.”

If the issue isn’t life-threatening, many surgeons, she explains, will see patients at their office to mitigate and treat the issue. Alternatively, your plastic surgeon may perform the fix at an affiliated hospital. This may be submitted to your insurance straight from the hospital.

What questions should you ask your insurance company?

Even with a letter of approval, it’s important you know you what’s really covered. Know your deductible and ask if your insurance company may cover pain medication. Patients can also purchase elective surgery insurance, such as CosmetAssure, which covers you up to 45 post-procedures for surgeries spanning cheek implants, abdominoplasty, lower body lift, liposuction and more. It does not cover patient dissatisfaction with the outcome.

Patients can also go in half medical, half cosmetic! Not only can it save patients money, but also additional hours of anesthesia. Surgeons routinely pair a hysterectomy with a tummy tuck or breast reduction. Call your insurance to learn how the bill will be split, it’s usually calculated in terms of percentage. For instance, if a double surgical procedure takes four hours and the cosmetic portion ran one hour, patients are responsible for 25 percent of the total bill.

Given the rise of plastic surgery, you can expect that insurance companies will become more and more restrictive on coverage, especially given the mandate on personal insurance. It’s a numbers game, so ask questions!

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