WHAT PLASTIC SURGERY IS COVERED BY INSURANCE?
Most people relate plastic surgery to cosmetic, or aesthetic, surgery exclusively. This is not a complete picture. Plastic and reconstructive surgeons perform all sorts of procedures, such: as breast reconstruction after a mastectomy for cancer, tendon reconstruction after a traumatic hand injury, or reconstruction of a leg wound after chronic vessel disease. None of these procedures would be considered cosmetic, and most insurances would fund the payment for the purpose of enhanced function. Strictly form-related conditions, however, are mostly not paid for by most insurance companies, unless that form-related condition is associated with other symptoms that limit a person’s function in a meaningful way that could be improved with plastic surgery. To understand the difference, one can compare a few procedures of the breast: breast reduction, breast lift, and breast reconstruction (after cancer).
Breast reduction, or reduction mammoplasty, and breast lift, or mastopexy, are two of the most common procedures in plastic surgery. Larger-than-desired breasts can cause neck and back pain, grooving where the bra strap sits, social self-consciousness, and impair activities like running and dancing. A breast reduction is the removal of breast tissue to result in a smaller breast. This is different than a breast lift, which also requires the removal of some tissue, but generally much less and only for the purposes of lifting, not to remove tissue or make the breast smaller. This is a key distinction because a breast lift is essentially never covered by insurance. However, a breast reduction is sometimes covered by insurance if certain criteria are met, such as taking off enough tissue to qualify the procedure as a reduction. While not all breast lifts involve size reduction, all breast reductions include a breast lift. The guidelines for how much is required to call a procedure a reduction in the eyes of an insurance company is determined by a patient’s height, weight, “body mass index,” and body surface area. This is outlined in the Schnur Scale, which is a list of breast tissue removal weights that are required to qualify for an insurance-covered breast reduction. So you basically have to have at least the mount to meet the Schnur Scale for an insurance-covered breast reduction.
Now compare the above to breast reconstruction. The Women’s Health and Cancer Rights Act of 1998 requires all group health plans that pay for mastectomy to also cover prostheses and reconstructive procedures. So, assuming you haven’t chosen a reconstructive procedure that varies from the standard of care, are working with a plastic surgeon outside of your health network or have some special exception in your plan (which your plan administrator could explain), then in virtually all cases the reconstruction after the removal of your breast tissue by mastectomy for cancer should be covered by insurance.
There are several other conditions in which insurance may or may not cover your procedure, such as panniculectomy (sometimes covered) versus tummy tuck (generally not covered). A panniculectomy is the removal of tissue from the lower abdomen for reasons of reconstruction to remove excess skin that may cause dermatologic problems and/or back pain. It does not include tightening of the deep abdominal wall, or a “rectus muscle plication,” or the repositioning of the belly button. A tummy tuck includes these techniques for the purposes of not only removing extra skin and soft tissue of the lower abdomen but also to make the upper abdomen and flanks look better. A tummy tuck sometimes includes liposuction, whereas a panniculectomy involves only direct excision of tissue.
If you would like to learn more about whether a surgical procedure you have been considering might qualify for insurance coverage, reach out to Kristopher M. Day, MD, FACS by emailing Info@PacificSoundPlasticSurgery.com to schedule a consultation. Dr. Day has extensive experience in many conditions for the improvement or both form and function and looks forward to speaking with you about your goals!
Breast reduction, or reduction mammoplasty, and breast lift, or mastopexy, are two of the most common procedures in plastic surgery. Larger-than-desired breasts can cause neck and back pain, grooving where the bra strap sits, social self-consciousness, and impair activities like running and dancing. A breast reduction is the removal of breast tissue to result in a smaller breast. This is different than a breast lift, which also requires the removal of some tissue, but generally much less and only for the purposes of lifting, not to remove tissue or make the breast smaller. This is a key distinction because a breast lift is essentially never covered by insurance. However, a breast reduction is sometimes covered by insurance if certain criteria are met, such as taking off enough tissue to qualify the procedure as a reduction. While not all breast lifts involve size reduction, all breast reductions include a breast lift. The guidelines for how much is required to call a procedure a reduction in the eyes of an insurance company is determined by a patient’s height, weight, “body mass index,” and body surface area. This is outlined in the Schnur Scale, which is a list of breast tissue removal weights that are required to qualify for an insurance-covered breast reduction. So you basically have to have at least the mount to meet the Schnur Scale for an insurance-covered breast reduction.
Now compare the above to breast reconstruction. The Women’s Health and Cancer Rights Act of 1998 requires all group health plans that pay for mastectomy to also cover prostheses and reconstructive procedures. So, assuming you haven’t chosen a reconstructive procedure that varies from the standard of care, are working with a plastic surgeon outside of your health network or have some special exception in your plan (which your plan administrator could explain), then in virtually all cases the reconstruction after the removal of your breast tissue by mastectomy for cancer should be covered by insurance.
There are several other conditions in which insurance may or may not cover your procedure, such as panniculectomy (sometimes covered) versus tummy tuck (generally not covered). A panniculectomy is the removal of tissue from the lower abdomen for reasons of reconstruction to remove excess skin that may cause dermatologic problems and/or back pain. It does not include tightening of the deep abdominal wall, or a “rectus muscle plication,” or the repositioning of the belly button. A tummy tuck includes these techniques for the purposes of not only removing extra skin and soft tissue of the lower abdomen but also to make the upper abdomen and flanks look better. A tummy tuck sometimes includes liposuction, whereas a panniculectomy involves only direct excision of tissue.
If you would like to learn more about whether a surgical procedure you have been considering might qualify for insurance coverage, reach out to Kristopher M. Day, MD, FACS by emailing Info@PacificSoundPlasticSurgery.com to schedule a consultation. Dr. Day has extensive experience in many conditions for the improvement or both form and function and looks forward to speaking with you about your goals!
