News & Features

Looking Good, Working Well... and Reimbursed

Functional Plastic Surgery Staff Report Medically Reviewed by
Elliot Jacobs, M.D., F.A.C.S.

CONSUMER BRIEF: Plastic and cosmetic surgeons say many patients are taken aback to learn their health insurance policies do not cover ordinary charges for cosmetic and plastic surgery operations. Meanwhile, other seekers of surgical rejuvenations are surprised to find that, in some cases, some health insurance policies will cover cosmetic surgical procedures if the operation helps a person function better.

A high school senior from Pittsburgh, Pennsylvania, became an outstanding golfer in high school and stood a good chance of getting a full scholarship at a college for playing on the golf team.

But something was holding her game back -- her extremely large breasts were in the way of her swing. Moreover, the added weight of the pendulous breasts caused poor posture, back problems and terrible skin rashes. In some women, pendulous, ultra-heavy breasts even create permanent grooves in their shoulder bones due to the extra ballast on the bra straps. The Solution? Surgically reduce the breasts. “The minimum requirement for insurance coverage is removing 350 grams (about 12 ounces,) from each breast,” plastic surgeon Leo McCafferty, M.D. in Pittsburg and a clinical assistant professor of plastic surgery at the University of Pittsburgh, told “Moreover, huge breasts are connected with long-term health problems like curvature of the spine and spinal arthritis. Plus, the teasing from boys is non-stop, sports and other activity are hampered and clothing doesn’t fit well.”

The good news: when all those conditions are present, most health insurance firms will pick at least some of the tab for a breast reduction. The procedure falls into an area between plastic and cosmetic surgery known as functional plastic surgery.

While breast reductions currently lead the list of functional plastic surgery operations, a few other surgical rejuvenations can also make the patient look and function better while receiving at least some insurance coverage. Typical procedures include the repair of crooked noses to allow better breathing and reductions of hanging upper eyelids to help patients see more clearly. Reconstructive surgery -- like cleft palate repair -- is usually limited to repairing abnormal bodily structures caused by birth defects, injuries, infection, tumors or disease. Most reconstructive surgeries are done with restored function uppermost in mind but may also create a more normal appearance along the way.

“A cleft palate repair is absolutely necessary because the child can’t eat normally otherwise,” says Valerie Ablaza, M.D., F.A.C. S., a New Jersey plastic surgeon. “But there’s no question that it makes the child look much better, too.”

Usually, a crooked nose results in blocked breathing passages. The operation to open those passages to restore normal airflow – but without beautifying the nose – is known as “Septoplasty.” In most cases, a crooked nasal septum – the wall that separates the two nostrils -- has been injured, often in childhood. As the person grows, the deformity becomes larger and eventually blocks airflow. Septoplasty repairs the block but probably won’t improve the appearance of the nose -- although it’s easy enough for a qualified plastic or cosmetic surgeon to do an aesthetic procedure at the same time.

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

Observes Steve R. Fallek, M.D., a plastic surgeon with offices in New York City and New Jersey: “Another leading request to insurance companies for coverage of a functional plastic surgery is for body lifts, after bariatric surgeries.”

Many more morbidly obese people – defined as those who have a Body Mass Index of 40 or over – are having operations to drastically reduce the amount of food their stomachs can hold. Afterwards, most typically lose anywhere from 100 to 300 or more pounds.

A typical patient described her plight: “After I dropped 155 pounds, it was like having a size 26 skin on my size eight body.”

But a huge weight loss also leaves large sheets of stretched skin hanging from the neck, arms, chests, legs and abdomen. It almost always requires another extensive surgical procedure known as body lifting, or body contouring.

“The huge mass of loose skin hanging from the stomach after bariatric surgery 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 by insurance.”

Other approved functional plastic surgeries include repairing improperly healed burns and scars.

“When burns heal improperly, scar tissue can cause an arm to contract so its reach is shorter,” says Ernest D. Cronin, M.D., F.A.C.S., a plastic surgeon at Christus St. Joseph Hospital in Houston, Texas. “We make repairs by cutting out the scar tissue and replacing it with skin grafts from other parts of the patient’s body. There’s no question but that the repair also improves the patients’ appearance.”

Other burns that may be eligible for insurance coverage are burn scars around the mouth which may prevent the patient from opening the mouth.

Other covered functional repairs that also enhance the patient’s appearance include 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 lost in accidents. Some surgeons 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 thus are covered even though the surgery makes the patient look much, much better.

Edward Jacobson, M.D., F.A.C.O.G., of the Laser Vaginal Rejuvenation Institute of Greenwich, Connecticut, says about one third of his patients’ procedures are covered by insurance – if a certain troublesome condition is also present.

“The time-honored repair for urinary stress incontinence and bladder repair is surgically close to an elective procedure known as a ‘vaginal rejuvenation’ which tightens muscles to bring about enhanced gratification of sexual relations,” says Dr. Jacobson.

Dr. Jacobson’s clinic offers an increasingly more popular procedure trademarked there as “Designer Laser Vaginoplasty” which is the aesthetic surgical enhancement of the vulvar structures.

“Some women have the procedures for purely cosmetic reasons while others have it done because it can make some jobs like horseback riding instructor or aerobics teacher better,” says Dr. Jacobson. “I had one such patient who could not easily ride a bicycle for exercise and had some of her vulvar structures reduced, with insurance coverage.”

One thing’s for sure: with somewhere between nine and 11 million plastic and cosmetic procedures done in 2004, more consumers are going to be asking their insurance companies which are covered.

You just can’t lose by looking and functioning better.

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