Does Health Insurance Cover Cosmetic Surgery?

Americans spend billions of dollars on cosmetic surgery every year, so it makes sense that you’d wonder if these procedures are covered by your insurance. However, before discussing the various scenarios in which insurance will cover cosmetic surgery, we have to first understand what constitutes cosmetic surgery.

Though often used interchangeably, plastic surgery and cosmetic surgeries are different things. Cosmetic surgery is focused on aesthetically improving appearance for self-esteem reasons. This includes procedures like:

Breast augmentation
Nose job
Liposuction

Plastic surgery, on the other hand, focuses on reconstructive procedures such as:

Burn repair
Scar revision
Breast reconstruction

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What Cosmetic Procedures Are Covered by Insurance?

It’s certainly a relief to know that some cosmetic and plastic surgeries will be covered by insurance, at least in part, given the large cost of these procedures. For example, a nose job usually costs around $5,000 and breast augmentation costs $3,700 per breast.

The extent of your coverage will depend on your specific insurance policy. However, the general rule of thumb is that insurance will pay for procedures that are deemed medically necessary.

That means that if you want breast augmentation just because you’d like larger breasts, then your insurance will not help out. But if you require breast augmentation after having a mastectomy, then your insurance will likely help cover the cost.

Different Insurance Plans and Their Cosmetic Coverage

Employer Sponsored Plans: In these plans, cosmetic surgery is only covered if a doctor or physician deems the surgery medically necessary.

On/Off Marketplace Plans: Cosmetic surgery is not one of the ten essential health benefits that all of these types of plans are legally required to offer. However, depending on which plan you purchase, medically necessary procedures to repair birth defects or reconstruct damaged body parts may be covered.

Medicare: Medicare does not cover cosmetic surgery unless the surgery is needed as a result of accidental injury, or to improve the function of a malformed body part.

Medicaid: Medicaid will most likely have similar coverage to Medicare. But different states have different rules about their coverage, so be sure to look into what is covered in your home state.

In all of these types of insurance, they key is the term “medically necessary.” In order to prove to your insurance provider that the cosmetic surgery you seek is medically necessary, you will have to provide proof. This proof should be in the form of written and photographic explanation of the situation from a doctor or physician, as well as proof that other non-surgical remedies have been tried already.

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Most Commonly Covered Cosmetic Procedures

With insurance only covering medically necessary procedures, you may be thinking that means only plastic surgeries are covered and not any cosmetic ones. While it is true that more often plastic, reconstructive surgeries are covered, there are still medical reasons for many cosmetic surgeries. Here are some common cosmetic procedures and the situations in which insurance is most likely to cover them:

Breast Augmentation: Under the Women’s Health and Cancer Rights Act, any insurance that covers mastectomies must cover breast reconstruction as well. You are also permitted to wait a few years after your mastectomy to get breast augmentation.
Breast Reduction: If you are a woman whose breast size causes significant pain, or if you are a man who has unusually large breasts, insurance may cover a breast reduction. You will require a doctor’s orders.
Butt Lifts: If you have a mastectomy and then a breast augmentation, the breast reconstruction takes tissue from your butt area. Since this is ultimately a side effect of a mastectomy, your insurance will likely cover a butt lift after such procedures.
Eyelid Lift: If your eyelids obscure your vision significantly, then you may be covered for an eyelid lift.
Nose Job: Your insurance may partially cover the cost of a nose job. If you have a deviated septum, then insurance will cover the cost of that repair. But if you wish to reshape your nose at the same time, that portion of the surgery will not be covered.
Liposuction: For people who are obese and whose quality of life is greatly impacted by their weight, insurance may cover liposuction. Be prepared to jump through hoops in order to prove to the insurance company that this is a medically necessary procedure.
Skin Folds: If skin folds are painful, limit your mobility, or lead to health issues such as infections, then an insurance company will be inclined to cover the cost of their removal.

Speaking to your insurance provider, your family doctor, and a board certified plastic surgeon will help provide clarity on what your options are to pay for cosmetic surgery.

Margaret Huntley Margaret Huntley is a creative writing and philosophy student at Western University. She has been working as a freelance writer for over two years and has written about everything from insurance, to poker, to health and wellness for international businesses.