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Insurance Coverage For Medically Necessary Cosmetic Procedures

1588 words - 7 pages

Insurance Coverage For medically Necessary Cosmetic Procedures

Melanie had a full facial cleft,and her brain could begin to push out through it. Pushing it back and closing the gap is a complicated , risky and expensive procedure to do . This is surgery where you peel the face off the skull, you have to make all these cuts and move it around, the brain is softly pulsating away behind the incision. Her doctor and parents, after discussing her case decided that the procedure would be worth the risks, however; the families insurance carrier called the procedure unnecessary or cosmetic and refused to pay for the nearly $10,000 surgery, Melanie's condition was not life threatening and ...view middle of the document...

This will give you a basic understanding of some commonly-used techniques in reconstructive surgery. It won't answer all of your questions, since each problem is unique and a great deal depends on your individual circumstances. Please be sure to ask your doctor to explain anything you don't understand. Also, ask for information that specifically details the procedure you are considering for yourself or your child. Insurance plans generally exclude coverage of cosmetic surgery that they do not consider medically necessary, but generally provide coverage when the surgery is needed to improve the functioning of a body part or even if the surgery also improves or changes the appearance of a portion of the body. Additionally, many plans specify that procedures are considered to be cosmetic surgery, e.g., surgery to correct the result of injury, post-mastectomy breast reconstruction, and breast reduction. They also exclude surgery needed to treat certain congenital defects such as cleft lip or cleft palate, birth marks and port wine stains. The term, “plastic and reconstructive procedures” includes procedures ranging from purely cosmetic to purely reconstructive . Benefit application has the potential to be confusing to
members because there is an area of overlap where cosmetic procedures may have a
reconstructive attribute and reconstructive procedures that have a cosmetic attribute.
These procedure benefits are authorized based upon the purpose of the procedure. Cosmetic procedures are those that are primarily intended to improve appearance. Reconstructive procedures are those procedures deemed medically necessary to correct gross deformities with impairments attributable to congenital defects, injury (including birth) or disease. The goal of reconstructive surgery is to correct an abnormality in order to restore physiological function to the fullest extent possible. For reconstructive surgery to be considered medically necessary there must be a reasonable expectation that the procedure will improve the physical impairment. The muscles of facial expression have a communication function that may be considered in determining medical necessity as a reconstructive rather than cosmetic service.
The most common cosmetic procedures are routinely performed to improve the contour of the face, diminish scars, or control acne and blemishes. According to The American Society for Aesthetic Plastic Surgery, more than 11 million cosmetic procedures were performed in the United States in 2007.

When considering whether or not to undergo a procedure, patients should examine treatment options and investigate the doctors background and credentials thoroughly. Many patient who undergo reconstructive surgery want to conform to social attitudes and norms rather than some disease or biological dysfunction. What distinguishes the distress suffered over some aspect of one's appearance from the pain, say, of a broken arm is that appearance is based...

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