Cosmetic surgery is the means by which a person chooses to have an operation or invasive medical procedure to alter their physical appearance with the goal of improving one’s self-esteem, confidence and look. Because cosmetic surgery is elective, typically medical insurance will not cover the procedures. However, cosmetic procedures that are deemed “medically necessary” can sometimes be included within the insurance policy. 

In June 1989, the American Medical Association clarified definitions of the terms cosmetic surgery and reconstructive surgery in order to determine coverage by health insurance companies. Cosmetic surgery is performed to reshape the normal structures of the body to improve appearance and self-esteem whereas reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. 

The most common type of reconstructive surgery that is also a cosmetic surgery relates to a woman’s breasts. The loss of breasts is obviously life changing and can have profound effects on self-esteem, body image and sexuality. Fortunately, with advanced surgical techniques, surgeons are able to remove the breast while saving the nipple and areola. In 1998, The Women’s Health and Cancer Rights Act was established requiring insurance companies to cover breast reconstruction, including the symmetry of the opposite breast, after a mastectomy. This also includes women who have not undergone a mastectomy but who carry a high-risk gene for breast cancer.    

In addition to reconstructing breasts or implants to enlarge the breasts, reducing the size of the breasts may be covered under insurance. Sometimes there are medically necessary reasons for a breast reduction, mammoplasty, such as chronic nerve pain, rashes under breasts, abnormal curvature of the spine, limitation of physical activities or tingling of the extremities. If a breast reduction surgery is considered a medically necessity, it is possible a health savings plan (HSA) or insurance company may cover surgery expenses with a diagnosis letter provided by a physician outlining that the surgery is needed to treat an illness or disease and not for cosmetic purposes. Most insurance providers will request an additional 6 to 12 months of documentation, along with treatment by a physical therapist, chiropractor, dermatologist or orthopedist to ensure other treatments have been ruled out before approving surgery. Keep in mind that most insurance companies also require meeting a predetermined threshold or deductible before paying for surgery expenses, if approved.

When in doubt, research your insurance policy, know your rights and select a board-certified trusted surgeon who will guide you through all the ways surgery will be a benefit to you-cosmetically, medically and financially. 

To learn more, call David W. Allison, MD at 703-754-8228 or visit online at WEBSITE.