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Health Insurance for Reconstructive Surgery

How popular is plastic surgery? Approximately five percent of the people in the United ushered in the new millennium with plastic surgery of one kind or another. That means, of the forty people who attended your office Christmas party, two of them may have gone under the knife. Since then the numbers have only increased. But how many of them paid for the work out of pocket? Did their insurance companies ever foot the bill? Is there any form of plastic surgery that agents have to pay?

 

Health Insurance for Reconstructive Surgery: What is Considered Reconstructive Surgery?

The fist step is to understand the different types of plastic surgery. Not all nose jobs are cosmetic; in rare cases, they may even be necessary. Plastic surgery breaks down into two broad categories: Cosmetic Surgery and Reconstructive Surgery. Though the outcome may similar, it’s the need that differentiates them. Cosmetic surgery is loosely defined as work done to improve the individual’s self-esteem or appearance. This category generally includes liposuction, brow lifts, nose surgery, facial implants (silicone injected into the lips and cheeks)—breast augmentation, reduction, and lifts—tummy tucks and the removal of spider veins. Reconstructive surgery, on the other hand, is deemed necessary in order to fix abnormalities caused by trauma, congenital defects, infections and disease, and developmental irregularities. It may also be utilized to improve body functions, and in fewer cases, give the patient a “normal” appearance. Common reconstructive work includes cleft lips and palate repairs, hand surgery, scar revision, skin cancer treatment, and even breast reconstruction and reduction. Consider America’s first victorious face transplant patient, Connie Culp. After surviving a shot gun blast to the face, and countless plastic surgeries, she became the first person in the United States to have the face of a donor successfully attached to her own marred visage. For the first time in many years Ms. Culp has her own nose. Extreme as this example may be, it’s clear to any insurance company that this procedure was done for a necessary reconstructive purpose. It’s the subjectivity of reconstructive claims (preference versus necessity) that has become the locus of this issue.

 

Health Insurance for Reconstructive Surgery: What Reconstructive Surgery will Health Insurance Companies Cover?

According to the American Society of Plastic Surgeons, there are a number of procedures that most types of health insurance companies will foot the bill for. Eyelid surgery may be covered when performed to correct vision problems related to drooping eyelids. Hand surgery to correct issues caused by carpal tunnel syndrome, fused fingers, and nerve or tendon injuries is often covered by insurance companies as well. Surgery to correct breathing issues related to birth defects and developmental deformities are also coverable. Even breast work, often considered a purely cosmetic operation, may be covered when performed to fix asymmetry, health issues related to large breasts, or reconstruction due to loss. This last category has become a hot topic for health insurance companies due to the Woman’s Health and Cancer Rights Act (WHCRA) issued in 1998. This federal law requires insurance companies that cover mastectomies to also provide for mastectomy related reconstructive surgery. This would include reconstruction of the breast on which the mastectomy was performed, work on the other breast to create symmetry, and even implants. This law, often referred to as Janet’s Law (after Janet Franquet- originally denied surgery after her mastectomy), targets self-funded groups, fully insured plans, and individual health insurance plans.

 

Health Insurance for Reconstructive Surgery: Is there Health Insurance for Reconstructive Surgery in Children?

Many of the congenital issues adults suffer through could have been fixed during childhood. But, in a recent poll given to surgeons in The American Society of Plastic Surgeons, it was found that fifty-four percent of the doctors had pediatric patients that were either denied coverage or had to overcome insurmountable odds in order to be approved for reconstructive surgery. Most insurance companies refuse to pay for operations they deem merely cosmetic; a decision left completely up to the adjusters. The only state where the government has stepped in to require companies to cover reconstructive surgery for children is Texas. Other states have attempted comparative legislation, but the laws are difficult to enforce on organizations regulated solely by federal criteria. That is why Carolyn McCarthy (D), Patrick Tiberi (R), and Bart Gordon (D), introduced the CARES Act to the House of Representatives on March 6th, 2009. Their desire is to see the Children’s Access to Reconstructive Evaluation and Surgery Act require insurance companies to cover surgery for developmental and congenital deformities, and disorders due to disease, tumors, and infections.

 

Reconstructive procedures have been deemed necessary by doctors for the normal functioning of their patients, but not all insurance companies will cover the cost. Is your health insurance provider sympathetic to the CARES Act and WHCR Act? In the event of an emergency, will you receive the care necessary to function to the best of your ability? By simply entering your zip code at the top of page you can receive free health insurance comparison quotes.

 

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