Over 50? Keeping Up With Your Healthcare Needs

Over 50? Keeping Up With Your Healthcare Needs

What Do Surgeons Consider When Classifying A Procedure As Reconstructive Or Medical?

Nellie Ryan

Reconstructive and medically necessary plastic surgery often faces a hurdle when it comes to how an insurance company might classify the procedure. It's fairly well known that insurance companies often won't pay for cosmetic procedures and that doctors need to show that something is reconstructive or medically necessary to get coverage.

Patients should know where the dividing line is between cosmetic and medical procedures to get a better sense of how their insurance company might see a particular procedure. While some procedures are obviously reconstructive (e.g., repairing damage after an injury or damage that's due to treatment of disease), others need to show that the doctor has given them careful consideration before classifying them.

Effects on Daily Life and Functioning

The body part that you want to have surgery on has to have a detrimental effect on your daily life if you want the surgery to be covered as medical. For example, if your upper eyelids are noticeably droopy, but they don't interfere with your vision, then the surgery to tighten them up would not be medically necessary. However, if the droopy skin were actually blocking your eye -- this can happen in severe cases -- then the surgery could be seen as reconstructive and medically necessary as your daily functioning is affected by the drooping skin.

Cause of Condition

Your doctor also needs to look at the cause of the condition. If you just happen to have a rather large nose due to genetics, and you're not experiencing breathing problems or snoring because of it, a procedure to reshape the nose would likely be cosmetic. However, if you had been in an accident and broken your nose (again, assuming there are no breathing problems as a result), surgery to return the nose to a shape that's closer to what it was like before the accident could be seen as reconstructive.   

How Surgical Results Might Improve Quality of Life

Another issue is how the results of the surgery might improve your life after the surgery. Breast reduction often faces this question. Women who need a reduction might not be waylaid by massive back pain every day, but if they are dealing with skin rashes from bra straps digging into their shoulders, for example, the effect of a reduction would be a reduction in pain and skin trauma. Thus there could be a medically necessary reason for breast reduction. Yet if the problem is really that there's a little shoulder discomfort that isn't doing much else than leaving a mild mark from the straps, a reduction might be seen as cosmetic in that case.

Classification is going to vary for everyone and for each procedure. If you are having an issue that you think would require plastic surgery and that would fall in medical and reconstructive categories, talk to a reconstructive surgeon for further clarification. Also, visit a site such as http://www.JGattiMD.com for more information and resources.


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About Me
Over 50? Keeping Up With Your Healthcare Needs

As an adult in my 50s, I find that my body isn't as strong as it used to be. But I don't let that stop me from enjoying life! In fact, I make every effort to get the treatments I need from my doctor to improve my health. I know that I'm not a senior yet, but I do all I can to prevent the health problems that affect that age group. Because of this, I put together a health blog for people over age 50. My blog isn't a review of what you can easily find on the Internet. It's a plethora of unique information designed to help you find the services you need fast. What my blog doesn't do is tell you what to do for your health. Instead, it offers guidance and options. Please, enjoy the blog and happy reading.