Would this procedure be covered by insurance?

Posted August 25, 2021

Patients often ask if their procedure would be covered by insurance. To be covered by insurance the procedure would have to be determined by an insurance company to be medically necessary to correct a functional problem. Insurance companies do NOT cover:

• Breast Lifts
• Arm Lifts
• Thigh Lifts
• Tummy Tucks
• Liposuction
• Lower Eyelids
• Gynecomastia
• Correction of Breast Asymmetry
• Scar Revisions

Your insurance company determines coverage and although patients often think that a letter from their primary care physician or potential surgeon will change that decision, it is entirely based on your provider and their coverage. 

Procedures that are covered must still meet requirements set forth by the insurance company. This may consist of months of preparation prior to the actual surgery to facilitate the authorization. The most common procedures covered by insurance are Breast Reduction, Upper Blepharoplasty, and a Panniculectomy. 

Patients interested in Breast Reduction typically present with large, pendulous breasts, pain in the upper back, lower neck, shoulders, and breasts. They have rashes that persist under the breasts and shoulder grooving from their bra straps. A Breast Reduction typically requires documentation from your primary care provider that this procedure is necessary. The patient may need 3 months of antifungal or hydrocortisone cream underneath the breasts due to a history of rashes. There is also typically documentation needed from a physical therapist or chiropractor.

Patients requiring an Upper Blepharoplasty present with excess skin along the upper eyelids that hangs onto the eyelashes. They have a sensation of very heavy eyelids and may have decreased peripheral vision due to an obstruction caused by their excess skin. Insurance coverage requires visual fields test by an eye doctor that supports a decrease in the patient’s visual acuity. 

A Panniculectomy patient presents with excess skin to the lower abdominal wall that hangs over their waistline. They generally have a history of rashes or infections to the abdominal crease. Patients frequently have pain along their hips and lower back. Insurance coverage requires documentation from their primary care physician and the use of antifungal or hydrocortisone cream treatment for their rashes or infections. If they have had weight loss or reduction surgery many times the insurance company will have them wait 18 months after the surgery before undergoing a Panniculectomy.

If you feel that you are a candidate for cosmetic surgery and are requesting coverage under your health insurance, it is important that you contact your carrier and have them provide their specific criteria for coverage approval. Each insurance company has different independent criteria and indications for coverage. It is never too early to start the process or have a conversation with your primary care physician regarding your healthcare concerns. Patients not approved through insurance may still pursue an aesthetic procedure in a self-pay manner.