Is Your Reconstructive Plastic Surgery Medically Necessary?

By Scott Glovsky on April 27th, 2020 in Insurance and Healthcare Denials

Has your insurance company denied your claim for reconstructive plastic surgery? It is not uncommon for a health insurers to deem a patient’s legitimate procedure as “not medically necessary” or strictly cosmetic. Despite its obligation to act in the best interests of plan members, health insurers often look for a reason to deny a claim. Health insurers sometimes deny a claim for reconstructive plastic surgery to save themselves money at the expense of a patient’s health and wellbeing. This article addresses common questions related to reconstructive plastic surgery versus cosmetic plastic surgery. It provides tips for those who have been wrongfully denied coverage for a medically necessary reconstructive surgery. Finally, it provides tips for those seeking to have their reconstructive plastic surgery covered by their health insurer.

How Do I Know if My Plastic Surgery is Reconstructive or Cosmetic?

Before undertaking any plastic surgery, you should determine whether the procedure is of a reconstructive or cosmetic nature. Hopkinsmedicine.org states, “Reconstructive plastic surgery is done to correct facial and body abnormalities caused by birth defects, injury, disease, or aging.” The aim of reconstructive plastic surgery is typically to aid body function. Reconstructive plastic surgery can also create a more typical look and help with self-esteem. People with birth defects and people with deformities generally qualify for reconstructive surgery.

According to Revere Health, “Cosmetic surgery is an optional, or medically unnecessary, procedure designed to improve someone’s appearance.” One example of cosmetic surgery is a breast augmentation that does not involve breast reconstruction. Following a radical mastectomy, a woman requires breast reconstruction to replace tissue and nipple. This surgery is reconstructive because it follows illness.

Breast Reconstruction Surgery

One of the most typical examples of reconstructive plastic surgery is breast reconstruction surgery following a mastectomy due to breast cancer. Whether a procedure like this is determined to be medically necessary can come down to the patient’s own attitudes and outlook. Medically necessary can also come down to discussing the procedure and possible outcomes with a physician. Breastcancer.org states “Whatever your age, relationship status, sexual activity, or orientation, you can’t predict how you will react to losing a breast.” A variety of feelings will accompany this loss, and it is important for the patient to discuss their thoughts, feelings, and concerns with a doctor to evaluate the best path forward. Having these conversations with a doctor can enable one to determine whether reconstructive surgery is medically necessary to maintain physical and mental wellbeing.

Other Common Reconstructive Plastic Surgeries

Other reconstructive surgeries can include breast implant removal, breast reduction, cleft lip and palate repair, congenital anomalies, gender confirmation surgeries, hand surgery, lymphedema treatment, microsurgery, migraine surgery, orthognathic surgery, scar revision, septoplasty, skin cancer removal, and tissue expansion. As with breast cancer surgery, patients should first discuss these procedures at length with a doctor, including the possible outcomes and side effects. The patient should discuss with their doctor whether the doctor believes that the procedure falls within the guidelines for medical necessity. In addition to medical necessity, a doctor will also need to consider other factors before approving reconstructive plastic surgery.

Regarding who is a good candidate for reconstructive plastic surgery, Revere Health offers, “It is up to the surgeon to determine if someone is a good candidate for surgery, but there are factors to consider.” After running a battery of tests to check for overall health, a doctor will be the best judge of who is a viable candidate for surgery.

Cosmetic Plastic Surgery

Cosmetic plastic surgeries are not medically necessary and will in most cases not be covered by a health insurer. Some examples of procedures deemed cosmetic include breast implants, liposuction, and face lifts. It is highly unlikely that a procedure will be covered by health insurance if it is intended only to superficially augment an already typical appearance of a body part. In some instances the difference between reconstructive and cosmetic plastic surgery can seem clear. However, in many situations it is harder to determine which category a procedure falls into.

Plasticsurgery.org states, “Reconstructive surgery is performed to treat structures of the body affected aesthetically or functionally by congenital defects, developmental abnormalities, trauma, infection, tumors or disease.” Sometimes reconstructive surgery can be performed to return a body part to a more normal appearance. Whether or not this surgery is considered reconstructive or cosmetic will be interpreted by the insurance company. The varying level of coverage comes down to situations that are not fully black and white. Plasticsurgery.org provides an illustrative scenario: “A perfect example is rhinoplasty (nose surgery) which is often performed to enhance the appearance of the nose but may also be required to restore normal nasal breathing and normal appearance after a bad nasal fracture.” If rhinoplasty were performed to correct a nasal defect or following a nasal injury, it would likely be considered reconstructive. If there are no such factors making the surgery necessary, it would likely be considered cosmetic.

Will My Health Insurance Provider Cover Reconstructive Plastic Surgery?

Whether your health insurer will cover reconstructive surgery or not depends on a number of factors. These factors include whether your doctor has deemed the procedure medically necessary and whether your health insurer concurs with your doctor’s opinion. Even if your doctor claims your procedure is medically necessary, the insurer could still deny the request if they do not fully understand the situation. In a worst case scenario, the health insurer acts in bad faith to knowingly deny a legitimate claim.

What Should I Do if My Claim for Medically Necessary Reconstructive Plastic Surgery is Denied?

If a health insurer denied you or a loved one a medically necessary reconstructive plastic surgery, please contact us for a free consultation. We can help you determine whether you should appeal the medical necessity denial. Sometimes an appeal can result in an insurer changing its decision and complying with coverage. Sometimes a lawsuit is the only way to obtain your rightful benefits. The Law Offices of Scott Glovsky can help you find the justice you deserve.