What Insurance Covers Cosmetic Surgery?

Are you interested to know what insurance covers cosmetic surgery? don’t worry, you are not alone in this. Sit tight as we unravel the essentials you ought to know about cosmetic surgery insurance coverage.

Given the high cost of medical insurance premiums, you’d think insurance companies would cover Cosmetic surgery. Unfortunately, when it comes to paying for physical improvements, you’re probably on your own.

Sure, your self-esteem may improve after that bump in your nose is removed, but that doesn’t mean insurance companies will reimburse you.

However, there are some instances where insurance for plastic surgery is available. Perhaps one of these scenarios applies to you or a loved one.

What exactly is cosmetic surgery?

Cosmetic surgery refers to procedures that alter the appearance of an otherwise healthy part of the body. Unlike reconstructive or other medically necessary surgery, the primary goal of cosmetic surgery is to improve our appearance rather than to meet medical needs.

Many surgeries can improve a person’s appearance, but to be officially labeled as “cosmetic surgery,” a procedure must meet a specific definition.

Cosmetic surgery, according to the Medical Board of Australia (MBA), is any medical or surgical procedure performed to “revise or change the appearance, color, texture, structure, or position of normal body features, with the dominant purpose of achieving what the patient perceives to be a more desirable appearance.”

The American Medical Association (AMA) issued guidelines distinguishing cosmetic and reconstructive surgery in 1989. The American Society of Plastic Surgeons (ASPS) adheres to these guidelines, which state that “Cosmetic surgery is used to reshape normal body structures in order to improve a patient’s appearance and self-esteem.”

Reconstructive surgery is used to restore normal appearance and function to body parts that have been deformed by a disease or medical condition.

It is typically performed to improve function, but it can also be performed to simulate a normal appearance.”

What is cosmetic surgery and what is plastic surgery?

Cosmetic surgery and plastic surgery refer to two distinct types of medical treatment. While cosmetic surgery is any medical procedure done to improve a person’s physical appearance by changing ‘normal body features,’ plastic surgery is a more specialized medical field that includes both cosmetic and reconstructive surgery.

According to the MBA, “reconstructive surgery differs from cosmetic surgery in that, while it incorporates aesthetic techniques, it restores form and function as well as appearance normalcy.”  Certain procedures may be eligible for different levels of Medicare and private health insurance, while others may not.

Cosmetic surgery, for example, that does not meet the definition of “clinically necessary.” or isn’t for a medical reason may not be recognized by Medicare, and may not be covered by health insurance, depending on a person’s policy.

Which Cosmetic Surgeries are usually covered by Insurance?

Several factors influence whether or not a procedure is covered by insurance. Whether the insurance company considers the procedure to be medically necessary is frequently the deciding factor.

As a result, cosmetic procedures are not covered. A patient who wants a facelift to address cosmetic signs of aging, for example, would not be covered by insurance. However, in some cases, even cosmetic surgery may be deemed necessary for health or functionality.

Many people, for example, have impaired vision as a result of excess eyelid skin that droops into their field of vision.

In this case, a blepharoplasty – or eyelid lift – may be partially covered by an insurance policy. A panniculectomy, or excision of excess skin on the lower abdomen, is another surgery that may be medically necessary at times (pannus).

This hanging skin severely impairs mobility for some post-weight loss patients and even causes chronic skin rashes, irritation, and infections.

Because coverage details and decisions vary greatly from case to case, it is difficult to say that a specific procedure is “often” covered by insurance.

Again, the reason for the surgery is usually the deciding factor in whether or not the procedure is covered by insurance.

Cosmetic surgeries that  could be covered by insurance

The following are some of the most common cosmetic procedures with justifiable benefits for insurance coverage consideration:

  1. Rhinoplasty: in the event of breathing or sleeping difficulties.
  2. In the case of impaired vision, blepharoplasty is performed.
  3. Breast implant removal: when a breast implant-related illness occurs.
  4. In the case of a chronic rash, infection, or other condition, skin removal surgery may be performed.
  5. Breast augmentation or reconstruction: in the case of a mastectomy for breast cancer

Rhinoplasty, also known as a nose job, is an interesting case in which patients frequently have the procedure performed primarily for medical/functional reasons but benefit from the cosmetic benefits of the surgery secondarily.

A nose job is performed on a large number of men and women to correct a deviated septum, small nostrils, or another mechanical flaw that obstructs nasal airflow and can cause difficulty breathing, difficulty sleeping, and even sleep apnea.

In many of these cases, rhinoplasty will be deemed necessary and, as a result, will be covered by the patient’s insurance.

Even though the procedure was not intended to be cosmetic, the patient may achieve a more appealing nasal contour as a result of the manipulation required during rhinoplasty.

What Insurance covers Cosmetic Surgery?

According to the Ombudsman, the cost of cosmetic surgery performed solely for the sake of appearances, including hospital costs, is unlikely to be covered by your private health fund.

However, there may be times when cosmetic surgery is also deemed medically necessary. In these cases, and if you haven’t already claimed it on Medicare, the cost of the procedure may be partially covered by your health fund if your policy covers plastic surgery and you’ve served out the necessary wait times.

These procedures may include burn surgery, tumor removal, or treatment for traumatic injuries. Remember that if you make a claim on the hospital component of your private health insurance policy, you will almost certainly have to pay an excess, so you will almost certainly have some out-of-pocket costs even if your insurer approves your claim.

Canstar research reviewed the Australian Prudential Regulation Authority’s (APRA) statistics on costs for all plastic and reconstructive surgical operations, which includes cosmetic surgery procedures, as a general guide (where the health insurer has decided to cover them).

The study discovered that out-of-pocket costs ranged from about $460 to $2,800 on average across all surgery types, depending on the type of health insurance policy the patient had, including whether they had a ‘gap agreement’ or a ‘no gap’ agreement with their insurer.

If no agreement exists, the insurer will most likely pass on all or most of the out-of-pocket costs, which may include any additional fees charged by a surgeon or other specialist above the Medicare Benefits Schedule fee.

If a policy includes a ‘gap agreement,’ it means that the health insurer will cover the out-of-pocket costs of a treatment (the gap payment) up to a certain amount.

A ‘no gap’ agreement means that the health insurer agrees to cover all out-of-pocket costs (usually with conditions, such as having the procedure performed at one of the health insurer’s nominated facilities and by a nominated specialist).

How you can get Insurance to cover your Plastic Surgery

Finally, whether or not your surgery is covered by insurance is up to your insurance company. However, there are a few things you can do to increase your chances of being considered for coverage and proving that your surgery is medically necessary, including:

  • Photographs and logs should be used to document your condition.
  • Keep meticulous records of all visits to the doctor, hospital, or other facility-related to your condition. This includes any purchased products or therapies.
  • You must be able to demonstrate that you have exhausted all other treatment options and that surgery is your last resort. Obtain written recommendations from your doctor and other medical professionals that the surgery you desire is performed for medical/functional reasons.
  • Choose a qualified, certified, and trustworthy surgeon and treatment facility.

What Insurance Covers Cosmetic Surgery? my final thought

If the sole purpose of your surgery is to improve your appearance, it is almost certainly not a covered expense. If, on the other hand, the procedure will correct or improve a legitimate medical concern, it may be partially or completely covered.

Individual circumstances and health plans vary greatly. If you believe your procedure might be covered, check with both your surgeon and your insurance company to confirm.

Only they can tell you whether your planned procedure is fully or partially covered by your insurance plan.

Also, keep in mind that your plan may have specific copays or deductibles for these types of procedures.

It is important to note that even when coverage is provided for reconstructive procedures, some form of pre-certification is usually required, so do your research before scheduling your procedure.

Frequently Asked Questions (FAQs)

The answers to the most asked questions relating to What Insurance Covers Cosmetic Surgery are seen below;

  1. Is there any type of insurance that covers a BBL?

The simple answer is ‘No.’ Because BBL is a cosmetic procedure, it is not covered by insurance. Best.

  1. Is it possible to justify cosmetic surgery?

Cosmetic surgeries are justified under a variety of titles,1,19 including the WHO definition of health for the convenience of complete physical, mental, social, and spiritual aesthetic surgeries that should be considered a step towards improving individuals’ health status.

  1. Is it really necessary to have cosmetic surgery?

Cosmetic surgery is used to improve a person’s overall appearance by reshaping and adjusting normal anatomy to make it more visually appealing. Cosmetic surgery, unlike reconstructive surgery, is not considered medically necessary.

  1. How does cosmetic surgery improve one’s self-esteem?

A new study suggests that people may be opting for plastic surgery to improve their mood. According to a study published in Clinical Psychological Science, plastic surgery patients may have more joy in life, a higher sense of satisfaction, and higher self-esteem.


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