Medically necessary services are generally services that are provided to enhance one’s quality of life, physical or emotional functioning, and promote adequate development throughout the lifespan. These services should be provided only after individualized assessment of each person’s needs by a physician, or otherwise qualified professional, and the least intensive and intrusive services necessary to achieve the desired outcome should be the services that are provided.

With specific regards to plastic surgery, any procedure conducted with the primary intention of improving appearance is generally not considered medically necessary, unless it can be documented that a specific disfigurement is directly impacting the quality of one’s life. Plastic surgery procedures that are conducted to improve functioning that happen to result in improved appearance, however, can be considered medically necessary. For example, if excess scar tissue is impairing movement or causing pain, the removal of this scar tissue can be considered medically necessary to improve functioning, yet will most likely also result in an improvement in appearance. Other surgical procedures that are generally considered medically necessary are the removal of tumors, dermabrasion to improve deep scaring, rhinoplasty to improve a sinus condition, and reconstructive surgery. Breast reductions that are conducted to alleviate back and neck pain should also be covered as medically necessary under most health plans that cover reconstructive surgery.

To ensure that a plastic surgery procedure will be covered as medically necessary, there are several precautionary measures that the consumer can take. First, it is important for the consumer to identify whether his or her insurance coverage falls under state or federal regulations regarding reconstructive surgery. This can be done with a simple phone call to the insurance provider. Once this is done, the consumer can research the legal requirements regarding plastic surgery for their insurance provider. Generally state laws require more coverage than federal laws do, although current legislation being passed through the House and the Senate is intended to legally require all insurance companies to cover reconstructive surgery, and to create a more comprehensive and clear definition of the difference between reconstructive surgery and cosmetic surgery.

To find the legal requirements regarding reconstructive surgery in each state, click here. This website generally discusses breast reconstructive surgery, but the laws outlined here should apply to all types of reconstructive surgery. Once the consumer understands what is covered in his or her insurance policy, then he or she can go to a practitioner who specializes in the specific surgery or procedure. It is important to ensure that the medical professionals evaluating the necessity of the procedure take careful documentation, including pictures when appropriate, to send into the health insurance company for approval. Once all of the necessary documents and medical referral for surgery are sent in to the insurance company, the insurance company will decide whether to approve or deny coverage. If coverage is denied, then the consumer can request a re-evaluation of the case and use documentation of state and federal law along with physician reports to support their request.  If the procedure indeed falls within the terms of coverage and the state and federal laws regarding coverage, then the recommended surgery should be covered.