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Looking & Working Better – Plus, Coverage


Functional Plastic Surgery

Looking & Working Better – Plus, Coverage Plastic and cosmetic surgeons say many patients are taken back to learn that standard health insurance does not cover most cosmetic and plastic procedures. Meanwhile, other seekers of surgical rejuvenations are surprised to find that, in some cases, many health insurance policies will cover surgical procedures that help a person function better.

In those cases, the best of three worlds come together. Not only does an enhancement make the patient look better, but a body part is surgically repaired. Plus, the patient’s insurance company chimes in with some bucks to foot at least part of the tab.

Reconstructive surgery is usually limited to repairing abnormal bodily structures caused by birth defects, injuries, infection, tumors or disease. The surgery is primarily done to restore function but may create a more normal appearance along the way.

But ordinary people who never thought about reconstructive surgery are candidates for functional plastic surgery. Typical procedures include repairs or crooked noses to allow better breathing and reductions of hanging upper eyelids that help patients see better.

“The number one functional plastic surgery right now is breast reduction,” says Steve R. Fallek, M.D., a plastic surgeon with offices in New York City and New Jersey.

Breast reduction surgery can relieve back, neck and shoulder pain and skin rashes caused by overlarge breasts. In some cases, pendulous, ultra-heavy breasts create permanent bra strap grooves in the bones of the patients’ shoulders.

“Breast reductions can also make mammograms easier to read,” says Grant Stevens, M.D., a Los Angles plastic surgeon.

However, health insurance firms can throw an Alice-in-Wonderland aspect into the mix,

“Five or so years ago, a doctor would say such-and-such an operation is medically necessary, the insurance company would approve it and the surgery would go forward,” says Valerie Ablaza, M.D., F.A.C.S., a plastic surgeon in Montclair, New Jersey. “Now, they require lots of documentation. Some want the patient to be within ten percent of her ideal weight. But that condition often can’t be met, thanks to the weight of the overlarge breasts. Other insurance companies want six weeks of physical therapy and an MRI scan of the patient’s spine and then an orthopedic evaluation before the operation. Still others want pictures of the rashes and ulcers on the woman’s chest.”

Once all the documentation is assembled, most insurance companies routinely deny the first request, hoping no follow up action will be taken.

“But we resubmit it, then appeal it and then get on the telephone and explain in person why the procedure is medically necessary,” says Dr. Ablaza. “I’ve seen some requests for functional plastic surgery take two weeks and I’ve seen some require six months.”

Usually, a crooked nose results in blocked breathing passages. The operation to open those passages to improve normal airflow – but without beautifying the nose – is known as “septoplasty.” In most cases, a crooked nasal septum has been caused by some injury to the nose, often in childhood. As the person grows, the deformity becomes larger and blocks the air flow. Septoplasty repairs the block but probably will not improve the appearance of the nose -- although it’s easy enough for a plastic surgeon to do an aesthetic procedure at the same time.

“Insurance firms are on guard against purely cosmetic procedures so the patient must pay for the aesthetic correction while the insurance company picks up the tab for the functional part,” says Jan Adams, M.D. a California plastic surgeon and host of the Discovery’s Channel’s “Plastic Surgery -- Before & After.”

Adds Dr. Fallek: “Another leading request to insurance companies for functional plastic surgery is to approve body lifts, after bariatric surgeries like gastric bypass.”

More morbidly obese people – defined as at least 100 pounds overweight – are having operations to drastically reduce the amount of food their stomachs can hold. Afterwards, they typically lose anywhere from 100 to 300 or more pounds. And that huge weight loss leaves large sheets of stretched skin hanging from arms, chests, legs and stomachs. It almost always requires an extensive surgical procedure known as body lifting, or body contouring.

“The huge mass of loose skin hanging from the stomach is known as a “pannus,” says Dr. Fallek. “It prevents the patient from moving or properly exercising, fitting into normal clothes and creates health problems on the skin under the stomach overhang. Its removal is often covered.”

Other O.K.’ed functional plastic surgeries include repairing improperly healed burns and scars which often limit the range of movement, breast reconstructions after cancer surgery, ear replacements for people who have been in accidents or fires and hand surgeries to replace fingers and finger tips taken in accidents. Some physicians consider asymmetrical breasts a functional surgery because when one breast is heavier, the woman’s back can become unbalanced, putting undue pressure on her spine.

In addition to a droopy upper eyelid that obstructs vision, a lower eyelid can hang out on the cheek or turn inward and irritate the eyeball with its eyelashes. Those conditions are usually not considered purely cosmetic and are covered even though the surgery makes the patient look much, much better.

If a functional procedure has changed a body image experts say you can also expect to go through some predictable psychological changes.

While a chemical peel or eyelid surgery results in a refreshed, younger-looking appearance, more extensive procedures like breast reduction and nose surgeries can have dramatic adjustments by allowing the patient’s image and self-confidence to flourish. Experts say it actually requires some months to adjust to looking so much better.

Results? Usually, the person becomes more socially outgoing, more effective at work and more at ease in relationships.

And, again, another three bases are covered.



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