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Will my health insurance cover reconstructive surgery?

Keep in mind...
  • Cosmetic surgery is usually done on an elective basis
  • Reconstructive surgery is performed out of medical necessity
  • If deemed elective, your health insurance may not cover the cost

Advances made in modern medicine are nothing short of incredible. What was once thought of as a lost cause, now is considered a routine reconstructive surgery.

Improvements in emergency care and field medicine have led to higher success rates for survival after accidents and other spontaneous trauma.

Your health should be top priority! Enter your zip code above to find affordable health insurance quotes in your area!

Who needs reconstructive surgery?

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Traumatic injury victims are not the only people who would need reconstructive surgery. Congenital defects, degenerative diseases, and developmental abnormalities are all conditions where reconstructive surgery would be warranted.

Treatment options for a single condition can vary greatly. Treatments run everywhere from tried-and-true basics to pricey cutting-edge procedures.

If you were the victim of such a trauma or condition, what options would be available to you? That depends on what you and especially your insurance company are willing to pay for.

What is the difference between reconstructive and plastic surgery?

Plastic surgery and reconstructive procedures are both alike and different. Most often, plastic surgery is an elective procedure that is not medically warranted.

Someone may want to change the shape of their nose or reduce the signs of aging by having a facelift. 

On the other hand, reconstructive surgery includes procedures that are deemed of medical necessity. Burns victims, individuals who have been injured in automobile accidents, and even those suffering from congenital defects fall into the category of needing reconstructive surgery.

Patients are often mystified by the subtle differences between cosmetic surgery and reconstructive surgery, which insurance companies consider when determining “medical necessity.”

Though reconstructive surgery is primarily to improve the function of tissues and organs that have been damaged by trauma or disease, there are exceptions to this general rule.

Most health insurance companies will cover a procedure to reconstruct a feature such as an ear after an accident or birth defect has left a noticeable disfigurement or loss.

In such a case, the desire to look normal and to not live with the distraction of feeling like a spectacle is not considered purely cosmetic.

The fact that most patients desire the semblance of a normal life more than anything speaks to the seriousness of their conditions.

Reconstructive Breast Surgery

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Another consideration is reconstructive surgery after a cancer surgery has left damage to organs or physical features. Hundreds of thousands of American women have breast reconstructive surgeries every year.

Though they may all be technically cosmetic, only about a third are elective augmentations. Most of these procedures are done in the course of breast cancer treatment and recovery.

Surgeons are able to perform reconstructive breast surgery by using the patient’s own abdominal tissue, resulting in a natural-looking shape without the use of implants. Materials foreign to the body have a host of issues on their own.

Using the patient’s own tissue eliminates the risk of rejection of the implant by the recipient’s body. Such advances increase the odds of successful reconstructive surgery.

Knowing what your health insurance company will cover can help you make the right decision concerning any treatment that could have negative consequences to your future wellness.

According to a recent study by the US Food and Drug Administration, 40 percent of women who had silicone breast implants required additional surgery within 10 years.

The amount of money your insurance company will be willing to pay toward future medical bills as a result of reconstructive surgery raises an array of other issues.

When buying health insurance, patients want the most comprehensive coverage they can afford. Unfortunately, there are numerous maladies that could ultimately require reconstructive surgery to correct.

Although it is impossible to predict what kind of care you will need in the future, a careful examination of your insurance policy can help you make decisions regarding your healthcare.

Thoroughly read any exclusion clauses your policy might have regarding plastic surgery. Some patients are surprised by what is not covered by their health plans.

For example, many insurers have ended coverage for circumcision of newborn boys. Anything that can be considered not medically necessary can be denied by your health insurance company.

A consultation with your physician and insurance representative will help provide the insurance company with pre-authorization for the optimal corrective procedure.

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