A WebMD reader recently wrote in with a question about health insurance coverage for reconstructive surgery:
How hard is it to get my insurance provider to cover a breast reduction? I am 22 years old about 5’9 and 180lbs with a 38g cup size. I am in horrible pain and don’t know how to go about getting one or how to get my insurance to approve it.
When it comes to having insurance pay for any procedure, the bottom line is: is it considered medically necessary? In the case of reconstructive surgery, that generally means is it needed to repair or preserve the healthy functioning of the body.
Exactly where that line is drawn depends on a person’s individual circumstances, rather than the specific procedure.
For example, breast reduction as in this reader’s case is generally viewed as reconstructive surgery and not cosmetic. Another woman interested in augmenting her breasts for appearance sake, however, would likely be turned down by her insurer for coverage of the procedure.
The same may be true for someone having a nose job to correct a deviated septum or surgery to lift drooping eyelids that impair vision. While these surgeries may have a cosmetic component, they also are also justified by a medical need that insurers are likely to cover.
Here are a few steps to take to gain approval from your health plan for reconstructive or cosmetic procedures.
• Check with your insurer in advance. In most cases you’ll need your insurer’s pre-authorization for the procedure to be covered. That will likely mean submitting medical records, letters from specialists who have treated you for long-term symptoms, and in some cases photos to support for the medical necessity of the procedure. You’ll want to work with your doctor on this. Most surgeons who do these procedures have a lot of experience working to get insurance coverage for their patients, and so will be knowledgeable about how best to proceed.
• Pay attention to details. With breast reduction surgery most insurers dictate how many grams of tissue must be removed from each breast for the procedure to be covered. Be sure to ask in advance what those requirements are, and then discuss that with your doctor.
• You can appeal insurer decisions. Don’t be deterred if your insurer initially denies coverage. You have the right to appeal your insurer’s decision, and you should. Those who appeal are often successful.
What experience have you had getting cosmetic surgery covered by insurance? Share your comments in the section below.
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