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Is rhinoplasty covered by my health insurance?

The lowdown...
  • Health insurance policies state the terms of coverage and this can include or exclude cosmetic plastic surgery
  • Obamacare reformed health insurance to require policies to offer essential health benefits
  • Cosmetic surgery is not an essential health benefit
  • Insurers can offer cosmetic surgery as an option but they are not required to do so by Obamacare

Rhinoplasty can be medically necessary or cosmetic depending on the particular conditions of each case. For health insurance purposes, there are standards that apply to cosmetic and medically necessary surgery. Insurers often cover reconstructive procedures for all or some of the costs; insurance rarely covers cosmetic procedures.

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Cosmetic Versus Reconstructive Procedures

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In simple terms, the purpose of cosmetic rhinoplasty procedures is to change or improve appearances. As a general matter, the purpose of reconstructive rhinoplasty is to correct an injury, treat a disease, or correct a defect.

The purpose of the surgery makes a difference in the likelihood of insurance coverage. Medical necessity is the key to getting coverage; it is minimum essential coverage.

Traditional Insurance Approach

Rhinoplasty went through an evolution over the past twenty to thirty years. In the US, the earlier practice accepted routine medical decisions on the necessity of surgical procedures. For example, a doctor could indicate a medical need such as a deviated septum and then proceed to add a related corrective surgery. The insurers usually paid the medical costs and the hospital costs.

Insurance Resistance

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Over the years, insurers have stiffened resistance to plastic surgery related to a medically necessary surgery. Looking for ways to cut costs and increase profits, the insurers began to question the medical determinations and looked for further facts and evidence to support the claim of medical necessity. They began to insist on certain conditions before approval of procedures. The below-listed items reflect the concerns of insurers.

  • Whether there was a congenital defect discovered near the time of birth
  • Whether the surgery is needed to correct or repair an injury
  • Whether the surgery is necessary to treat a condition or disease
  • Whether the procedure is needed to repair a functional impairment
  • Whether the procedure is needed to correct complications from a previous surgery

Coverage Depends on the Policy

Insurance companies have continued to resist covering cosmetic procedures, and medical practitioners continued to add cosmetic procedures to repairs of functional defects.

Consumers can add specific types of coverage and customize a plan. Elective surgery coverage may be available through employer-sponsored insurance that offers a menu of additional protections.

Consumers Can Appeal

If insurers deny coverage for surgery, then consumers have rights to appeal the decision. The Affordable Care Act appeal rights apply to every policy, and they can get independent, external reviews of the medical necessity for a procedure.

Obamacare and Rhinoplasty

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The Affordable Care Act did not intend to tip the scales to either side in the battle over rhinoplasty surgery coverage. Obamacare left the determination of medical necessity to the medical professionals.

Obamacare does not prohibit insurance coverage for cosmetic procedures directly, but it does impose limits on high-end plans, and this annual dollar limit could eliminate coverage of elective surgery.

Grandfathered Plans

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The Affordable Care Act grandfathered coverage from many large employers and union-sponsored groups. These plans provide major medical coverage but do not have all of the protections that Obamacare Marketplace policies offer.

Consumers must review their benefits carefully to determine coverage of rhinoplasty and related costs. Some policies that will not cover cosmetic surgery will cover some the hospital fees such as the operating room fees, and hospitalization.

The Essential Health Benefits

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The Affordable Care Act requires insurers to offer qualified health plans. These plans offer 10 essential health benefits. Many of the essential benefits cover medical areas that involve reconstructive and corrective surgery.

  • Maternal and newborn care could involve birth defects and congenital defects.
  • Hospitalization and surgery benefits cover medically necessary rhinoplasty procedures.
  • Rehabilitative and habilitative services involve procedures to treat chronic conditions.

State Laws Can Add Protection

State laws may add protection and require coverage of certain cosmetic corrective surgical procedures. The federal laws in the Affordable Care Act and other national authorities provide a framework for insurers to determine coverage of cosmetic and reconstructive procedures.

State laws also can add requirements. For example, the California statutes define reconstructive rhinoplasty as that which is medically necessary to treat congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.

Using HSA, FSA, and HRA

For consumers, the goal may not be coverage as much as financing the expenses related to rhinoplasty and other elective procedures. These include hospital fees, specialists, anesthesia, and hospital stays. The items below describe the use of account-based funds to pay medical expenses such as the costs of rhinoplasty.

  • Health Savings Accounts provide funds for medical expenses. The funds are not limited to essential benefits, and they may cover hospital expenses related to surgery.
  • Flexible Spending Accounts give consumers control over when and how much to spend on their medical care.
  • Health Reimbursement Arrangements provide employer funds to reimburse medical expenses.

Is rhinoplasty covered by health insurance?

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Most insurance plans cover the medically necessary reconstructive surgery. Few policies cover elective surgery unless there are some specific terms to do so. Rhinoplasty and other elective or cosmetic procedures may be covered by qualified health insurance, but it is not required by Obamacare.

Coverage depends upon the terms of each policy. Medical doctors may have to go to some length to justify the expenses to an insurance company, but most insurance will cover medically necessary procedures that respond to conditions including injury, illness, disease, deformity, and congenital defects.

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