NYSHIP Empire Plan Plastic Surgery: What Is Covered in 2024?

Woman deciding on breast reconstruction flap vs. implant.

If you examine your NYSHIP Empire Plan plastic surgery coverage, you will come across something that says cosmetic surgery is excluded from coverage. But if you look closely, you’ll notice an asterisk that leads you to the exception — when plastic surgery is considered medically necessary, it may be covered by your NYSHIP Empire Plan in 2024. 

When Does Insurance Cover Plastic Surgery?  

Your NYSHIP Empire Plan may cover plastic surgery when a doctor determines it’s medically necessary. Medical necessity means it will resolve a condition that hasn’t been resolved with conservative or non-surgical treatments. A classic example is a woman who suffers from chronic neck and back pain due to large breasts. If the woman can show a history of chronic pain or skin conditions from her large breasts that haven’t resolved through alternative means (e.g., exercise or better, more supportive bras), breast reduction surgery would be considered medically necessary and possibly covered by the NYSHIP Empire Plan in 2024.

Plastic surgery may also be covered for other reconstructive purposes. Specifically, women who have had treatment for breast cancer or choose to undergo a prophylactic mastectomy are entitled to breast reconstruction surgery of their choosing (including aesthetic flat closures) and potential revision reconstructions if they experience pain, scarring, or deformity from their first procedure. 

The nuances of insurance and the documentation for verifying a medically necessary surgery can be complicated and confusing. That’s why choosing a plastic surgeon with a dedicated insurance liaison who can help you coordinate treatment with your insurance provider is essential. 

NYSHIP Empire Plan Plastic Surgery: 2024 Coverage at a Glance 

It’s important to remember that no one can guarantee your insurance coverage but your insurance company. However, there are quite a few plastic surgery procedures often determined to be medically necessary. 

Here are a few traditionally deemed cosmetic procedures that are often approved as medically necessary and covered by insurance. 

 

What It Is

When It’s Covered

Breast Reduction

Breast Reduction Surgery

Breast reduction, aka reduction mammoplasty, is a surgery to remove excess breast tissue and reshape the breasts. Along with reduced back pain, neck pain, headaches, and the resolution of skin conditions, this surgery also has quality-of-life benefits such as improved ease of physical activities and body image.

Breast reduction surgery is considered medically necessary when patients have specific symptoms that don’t resolve with conservative treatments. These conditions typically include chronic neck or mid-back pain, shoulder grooving, or chronic skin irritation beneath the breasts. 

Breast Reconstruction

An icon showing surgical lines on the breast.

 

Breast reconstruction involves using surgical techniques such as implants or natural tissue to rebuild the shape and fullness of the breast mound. Reconstruction surgery may also include cosmetic additions like areola and nipple reconstructions. An aesthetic flat closure after mastectomy is also typically covered after mastectomy.

Breast reconstruction is considered medically necessary after cancer diagnosis and mastectomy, or prophylactic mastectomy, as mandated by New York state and federal laws. Reconstructive surgery is also covered after breast conservation surgery, such as lumpectomy or oncoplastic reduction.

Revision Breast Reconstruction

Revision Breast Reconstruction

After reconstructive surgery, an individual might begin to notice issues with their breasts, like hardening of their implants or asymmetry in their breast shapes or sizes. A revision breast reconstruction corrects these problems.

If the initial breast reconstruction was covered by insurance, then the breast reconstruction revision is typically covered as well.

Mohs Reconstructive  Surgery

Mohs Surgery Reconstruction

A specialized dermatologist performs Mohs surgery to remove skin cancer. It can result in open wounds of the face or other areas that can often not be closed easily without leading to a deformity. 

A plastic surgeon can perform Mohs reconstructive surgery using specialized techniques to immediately close these wounds, helping the patient avoid deformity and improve scar appearance.

If the Mohs surgery to remove skin cancer was covered by insurance, the Mohs reconstructive surgery would also be covered.

Your plastic surgeon should work closely with your dermatologist to ensure you get the best result.

Rhinoplasty 

Rhinoplasty is a surgery designed to change the nose's size, shape, and appe

Rhinoplasty is a surgery designed to change the nose’s size, shape, and appearance. It is also performed to improve the breathing function of the nose.

If someone has severe airway obstructions due to a deviated septum or previous injury, rhinoplasty may be considered a medically necessary surgery.

Scar Revision Surgery 

Scar Revision Surgery

In scar revision surgery, a plastic surgeon removes or releases the scar deformity and rearranges the tissue to change the tension of the skin. This can also minimize the scar’s appearance.

Scar revision surgery is occasionally covered as a standalone medical issue. It’s typically covered when the scar causes discomfort or impacts function—for example, if a scar on your cheek prevents you from fully opening your eye.

The thing to remember when trying to determine your NYSHIP Empire Plan plastic surgery coverage is that it has to be about function. How will this plastic surgery meaningfully improve your quality of life — in a way that can’t be accomplished through alternate methods? The best thing you can do if you’re considering plastic surgery is to work with a provider who understands the ins and outs of medically necessary surgery and has the expertise in the office to help you get the most from your insurance coverage. 

Bringing Patient Advocacy to Breast Reduction and Reconstruction

At Harris Plastic Surgery, we are very familiar with the ins and outs of NYSHIP Empire Plan plastic surgery coverage. We can walk you through your options so you can get the right treatment under the coverage you’re entitled to. Contact us to schedule a consult.

Joanne Parrinello, Practice Manager

Joanne Parrinello is an expert patient care coordinator, with two decades of experience navigating the complex financial side of medically necessary breast reduction and reconstruction surgery. She acts as a guide to patients, helping them understand their options and their expected out-of-pocket expense. The insurance industry can be complex and filled with jargon that makes you feel like you need a translator. At Harris Plastic Surgery, Joanne is that translator.

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