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Here is When Insurance Will Cover for Plastic Surgery!

Are you opting for a plastic surgery procedure and are wondering whether your insurance company will cover it? Well, the answer is that you may not get a purely cosmetic procedure covered by health insurance.

However, in some cases, where the procedure is a medical requirement, you may get the support of health insurance. For example, if you are getting a breast reduction procedure to treat your back, you may get it covered – especially when it includes another procedure of skin removal after dramatic tissue removal. The bottom line is you have to establish a strong cause for why you need the procedure. You won’t get support from the health insurance company if your primary objective is just good looks.

Following are some of the main points on the checklist that insurance companies can consider before funding your plastic surgery.

Is There a Medical Requirement for the Procedure?

You may not get a clear answer to this question. What is considered medically necessary for one may not be considered a necessity for another.

However, some reconstructive operations, such as breast reduction surgery and eyelid operation, are considered purely cosmetic procedures.

Your insurance company may then follow definitions as per the American Medical Association (AMA) to find out whether the procedure can be covered or not. As far as reconstructive surgeries are concerned, procedures that deal with congenital defects – trauma, infection, birth defects, and such – can be covered by insurance. These are the types of surgeries that can improve the functionality and appearance of a human being. For instance, if a child is born with deformed ears or ends up with them because of an underlying condition, insurance companies will cover the expenses of the essential reconstructive surgeries. However, procedures like that of enhancing complexions or reshaping butts are unlikely to get a nod from insurance companies.

The Impact of the Condition on a Person’s Daily Life

Some insurance companies may also consider whether that deformity or condition is impacting the person’s lifestyle. If it is affecting your daily chores, such as exercising or taking a shower, then they may consider funding your case. Some specific conditions, such as a woman having trouble moving around due to her heavy chest or excess skin hampering movements of a person who lost some weight, which largely affects a person’s life are likely to get approved by the insurance company.

The Requirement for Photo Documentation

Sometimes the insurance company will require photo documentation to verify if the person is really suffering from the mentioned condition and if it is as bad as they claim. The visual proof aids the insurance claim process and is a solid addition for both parties. It leads to a stronger case and an easier decision-making process. Hence, it has become a necessary evil due to frequent requests for reconstructive surgeries made to the insurance companies.

Weight-Loss Surgery Insurance

There are certain procedures, such as weight loss surgery (namely bariatric surgery) that may get the approval of a health insurance company. This, however, happens with the application of certain conditions. For instance, the person should be older than 18 years, their BMI has to be more than 40, and they may be suffering from co-morbidities, such as cardiovascular diseases and Type 2 diabetes. Some of these weight-loss surgeries include Gastric Bypass, Sleeve Gastrectomy, Roux-en-Y Gastric Bypass, Laparoscopic Gastric Banding.

As a Last Resort

Another important criterion that most insurance companies consider is whether the primary line of treatment has been tried. For instance, whether the patient has tried medication, physical therapy, or any other procedures prescribed by the doctor.

If the primary course of treatment has been tried without much success and plastic surgery is the last resort, the case may be considered by the insurance company. The company may evaluate the situation and look into the details of all the conservative measures that have been tried. Once they have exhausted their resources to investigate possible alternatives, only then the cosmetic surgery procedure will be considered.

There are many more points to consider before your health insurance company will agree to release funds for your impending procedure. All plastic surgeries come with certain risks. Although in most cases they enhance the look of the patient, yet they can be life-saving in some cases too. The patient should make sure to go through the details and finer points with a doctor before saying yes to a procedure.

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