You’ve heard it called a beauty mark, but you don’t think it’s so beautiful. If you decide to have that mole removed, will insurance cover it? According to Dr. Johnson, “even if the mole turns out to be benign, insurance will usually cover its removal if it strikes a doctor as suspicious.” Suspicious moles include moles that have grown or shrunk or otherwise changed, moles with a diameter larger than a pencil eraser and moles that bleed or itch. If it does turn out to be cancerous, Dr. Johnson adds, “your insurance plan should also cover surgery to reconstruct your appearance.” As with most of these surgeries, pre-certification is generally required for reimbursement or coverage, so be sure to consult with your insurance company in advance of any surgery.
Breast augmentation costs Americans more than a billion dollars last year (with each surgery costing an average of $ 3,719 for the physician’s fee alone, not including anesthesia, operating room facilities, and related expenses). So if you’re asking, “Does insurance cover plastic surgery?” then there’s a pretty good chance you’ve got breast augmentation on your mind. As you may suspect, your health insurance won’t pay for you to get yourself a bigger set just because you want them. However, there are circumstances when your insurance will pay. Dr. Johnson explains that when you talk about plastic surgery covered by insurance, the question always comes down to what is “cosmetic” versus “reconstructive.” “It’s cosmetic if it’s simply the altering of the normal to make it look better but still normal. Aging is normal, so if someone comes in for work on their breasts due to the normal aging process, we consider that cosmetic,” Dr. Johnson explains. “If it’s addressing functional disabilities and deformities, it’s reconstructive.” But the notion of what is “normal” and what is a “deformity” is constantly evolving, as Johnson points out.
Since 1998, insurance companies have been required by law to cover not only breast reconstruction following mastectomy but also reconstruction of the other breast to make breasts look symmetrical and balanced after mastectomy and any physical complications at all stages of mastectomy. This includes revising previous reconstructions, points out Maria LoTempio, MD, a New York-based plastic surgeon specializing in reconstructive and cosmetic surgery exclusively for women. That means that following an initial reconstruction, a woman can opt for a different reconstructive approach for the purpose of enhancing the aesthetic result. Dr. LoTempio notes that the likelihood of insurance covers diminishes as time passes following the initial reconstruction, although in one case, a patient received full coverage for significant revision nearly eight years following her initial surgery. Dr. Johnson suggests that patients read their plans carefully and work closely with customer service representatives at the insurance company to determine whether the desired surgery will be covered. A review of a paper prepared by the ASPS regarding a form of revision known as fat grafting (which transfers to the breast fat that’s been removed from other parts of the body via liposuction) indicates that insurance companies can vary widely in their coverage.
Apart from breast reconstruction, Dr. Johnson points out that women who have already undergone a “boob job” may be able to have the removal of their implants paid for by insurance if the implants are found by a doctor to be faulty. Although insurance won’t cover the replacement, most implants now come with a lifetime warranty. As such, the implant manufacturer will pay for the replacement, and some manufacturers go so far as to cover the operating room expense for 10 years following the initial implant surgery. Here’s everything you always wanted to know about breast implants.
On the flipside is breast reduction surgery, the average cost of which is $ 5,631. During breast reduction, the surgeon removes fatty tissue, glandular tissue, and excess skin. Women may choose breast reduction to address both physical and emotional discomfort. Although insurance companies tend to use cup size as a guideline (often denying coverage if you’re not a “DD or larger,” notes Dr. Johnson), the ASPS recommends to insurance companies that the determination should focus not on how large the woman’s breasts are, but on the severity of a woman’s symptoms. For example, the weight of very large breasts can cause neck, shoulder, and back pain, leading to pain and discomfort during day-to-day activities. A woman may also experience rashes and yeast infections where her breasts fold over her torso. All of this may contribute to severe emotional pain as well.
“If her nipples are pointing to the floor, it’s obviously a problem,” says Dr. Johnson, “but it depends on the subjective thought process of the reviewer.” Dr. Johnson recommends documenting the symptoms and their duration (some insurance companies won’t consider paying for breast reduction until the symptoms have gone on for at least a year). She also recommends documenting all non-surgical measures taken by the woman that have failed (such as diet, exercise, supportive bras, chiropractic, and massage). It’s also a good idea to document the woman’s willingness to endure scarring in the interest of relieving her symptoms, Dr. Johnson adds, because this shows that her desire for the surgery isn’t frivolous. Don’t miss these 8 things you should know before going under the knife for breast reduction surgery.