This Article Has Been Medically Approved By

Dr. George H. Sanders

“Will my health insurance pay for part of or all of my procedure?” This question is one that I hear all of the time. Although an obviously cosmetic operation such as breast augmentation or facelift would not merit insurance participation, others such as eyelid lifts or nasal surgery may. Furthermore, a breast reduction of significant degree would almost certainly involve insurance coverage. How can a patient make sense of all of this?

Here are some questions to consider:

1. Is the procedure in question being done for improvement of the health of the patient (e.g. to improve impaired nasal breathing or to alleviate back pain resulting from excessively large breasts) or to correct a deformity that arose from necessary surgery (e.g. a mastectomy) or to repair an injury (e.g. a large laceration)?

This type of operation would be considered to be non-cosmetic or reconstructive surgery. If the answer to any of those questions is yes, then I will send a preauthorization letter to the insurance company to inquire as to whether coverage would be available. Along with the letter I will often include photographs of the body part under discussion for surgery as well as supporting letters from other health care providers who believe that surgery is an appropriate treatment for the patient’s problem. These are the possible responses from the insurance company:

a) “No, it’s not covered.” – The patient must then decide whether they want to pay    out-of-pocket for the operation.
b) “Yes, it’s covered.” – The patient may then schedule surgery as they desire, with the understanding that after the insurance company pays its portion of the surgical fees, there are usually monies owed by the patient for the deductible and co-payment.
c) The insurance company will not consider our request for preauthorization. Medicare follows this policy in all cases since they will not reply to any letters inquiring as to coverage for surgery. The patient must decide if they are willing to pay for surgery out of pocket. After surgery is completed we have the option of billing the insurance company and if money is received, that is refunded to the patient.

2. Is there any reason to bill the insurance company for a procedure if the procedure does not meet the requirements listed in section 1 above? The answer is maybe. Insurance companies are very clear about not covering cosmetic surgery. On the other hand, there are gray areas. Perhaps a woman with large breasts does not have a great deal of problems related to her breasts, but she has some. Even if the preauthorization letter is denied, it may make sense to have the patient pay for surgery, to do the surgery, and then go ahead and bill the insurance company and see what happens. Sometimes they do pay. On the other hand, if I personally do not feel that the procedure qualifies as reconstructive, I do not believe it is ethical to bill the insurance company for it. For instance, if a woman is undergoing a breast reduction that is going to be covered by her health insurance and I am also performing liposuction of the side of the chest for cosmetic reasons, I would view that liposuction as cosmetic in nature and therefore not eligible for insurance coverage. For that reason, it should not be billed to the insurance company.

3. What about an operation that has both a cosmetic and non-cosmetic part? What if a patient wants to have a rhinoplasty as well as straightening of a deviated septum that is interfering with breathing? In such a case, we will attempt to preauthorize the portion that we consider to be reconstructive – the septal straightening – and charge the patient a cosmetic fee for the rhinoplasty that is the cosmetic portion.

What do you think? Please leave a comment. Thanks!

George Sanders, M.D.