PLASTIC SURGERY
Reconstructive Surgery: The Gray Area
By Gary Viscio, Esq.
Although most people simply use the term Plastic Surgery, there actually is are differences within the term “Plastic Surgery” itself. The American Board of Medical Specialties identifies 24 medical subspecialty boards offering certification. Plastic Surgery is identified as one of those specialties. According to the American Society of Plastic Surgeons, Board Certification is a rigorous process involving extensive training and adherence to a strict ethical code. Ok, so enough with Plastic Surgery, that’s not what we’re here for is it.
Hence the “gray area.” While practicing in the insurance field I use terms, grey terms, as a way to turn an insurance company’s language on itself. For instance, common in bariatric surgery requests is the term “sufficient documentation” of failed dietary attempts. So, you define it. Is it one letter from your doctor, is it copies of years of progress notes, is it one year, five? Ten?
Within plastic surgery are the two major sub-categories of surgery. While the terms “cosmetic surgery” and “plastic surgery” interchangeably, they refer to very different techniques, procedures and practices.
Cosmetic Surgery normally refers to procedures that are used to improve or change the appearance of a nose, eyes, eyebrows or other facial features, as well as body appearance such as breasts and lately arms and legs. It is always an elective surgery since it is not medically indicated for improving a patient’s physical well-being.
The motivation for much cosmetic surgery is often self-esteem. Cosmetic surgery can help people remove or change a certain physical feature that, as a result, makes them happier with their appearance and enhances their self-confidence, as well.
The goals of Reconstructive Surgery differ from those of cosmetic surgery. Reconstructive surgery is performed on abnormal structures of the body, caused by birth defects, developmental abnormalities, trauma or injury, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Reconstructive surgery is generally covered by most health insurance policies although coverage for specific procedures and levels of coverage may vary greatly.
There are a number of "grey areas" in coverage for plastic surgery that sometimes require special consideration by an insurance carrier. These areas usually involved surgical operations which may be reconstructive or cosmetic, depending on each patient's situation. For example, eyelid surgery (blepharoplasty) - a procedure normally performed to achieve cosmetic improvement may be covered if the eyelids are drooping severely and obscuring a patient's vision. Further, overlapping with cosmetic surgery, especially regarding the restoration of normal appearance after massively invasive operations like mastectomies (breast removal). A portion of this particular procedure is plastic surgery; a portion can be considered cosmetic surgery.
A baby that is born with a cleft palate needs surgery to correct that condition, and this would be considered plastic or reconstructive surgery. Because the cleft palate can be a serious problem and affect quality of life, it is a medically necessary procedure.
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And there’s the rub; “Medical necessity” is an important distinction between cosmetic surgery and plastic surgery, which is why plastic surgeries aimed at restoring normal functioning are generally covered by insurance. Cosmetic are always elective as the procedures are not “medically necessary” so the cost of cosmetic surgery must be borne by the patient. Altering the shape of a patient’s body for the purpose of making the patient feel better, more emotionally than physically most of the time. Reconstructive surgery on the other hand, helps patients to regain functionality, which has positive effects both emotionally and physically and normally is covered by insurance carriers. Medical insurance plans do not cover surgery that is not required for the maintenance or improvement of a patient's physical health. Now what? Well, first, take a look at your insurance plan. The plan should contain a definition of Cosmetic and Reconstructive Surgery. Read the definition of Plastic Surgery and the sub categories of Cosmetic Surgery and Reconstructive Plastic Surgery. Don’t take anyone’s word for it, don’t ask the question over the phone, don’t ask me. Read it. See it. The only thing that matters is what is written in your insurance plan that is in the effect at the time you are seeking the treatment. Not last years, or next years, but this year, right now, while you’re seeking the surgery. What does your insurance company say about it. Secondly, what you must do is make sure you fit your claim within that definition of reconstructive surgery and medical necessity. If you’re seeking removal of excess skin of any part of your body, including your stomach, an abdominoplasty, or even breast lift or augmentation, you must make sure your doctor explicitly documents the reasons for the surgery, and uses the correct terminology. For your part, you must document your rashes, sores and any other skin eruptions. Make sure you see a dermatologist who documents your complaints, and will ultimately show what you already know, that there is no other way to cure your problems than surgery. Keep a list of prescriptions, as well as the empty tubes, over the counter receipts, and prescription bottles. Likewise, many carriers ask for documentation of difficulty in ambulation (walking around) due to excess skin. So your orthopedist and/or chiropractor will likewise need to document the problem, in detail your problem, whether your plan requests proof of difficulty in ambulation or not. If you have back, leg or hip pain, trouble walking, a change in your gait (walk/stance) because your weight has been drastically reduced after years of walking in a certain way, redistributed, and your extra skin is now in the way of what could is now a smaller framed person. So….. Document, document, document. Without it, you’ll never make medical necessity and you certainly won’t slide your case from the cosmetic side to the reconstructive side. Remember a goal of reconstructive plastic surgery is to “reshape abnormal structures of the body, improve function, and/or allow a person to have a more normal appearance,” and those goals as we know overlap with cosmetic surgery which is where your reconstructive surgery documentation protects you and shows your carrier exactly why you need this surgery, why it’s reconstructive and why it is medically necessary. If they deny for more documentation, give it to them. If they deny and say it’s reconstructive surgery, use your documentation and their own definition of reconstructive surgery against them. It’s not as easy as it sounds, but, we do it all the time, with proper medical records, and so can you. Most of all, best of luck and be well. |
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