NYSHIP Empire Plan Plastic Surgery: What Is Covered?

Woman deciding on breast reconstruction flap vs. implant.

If you examine your NYSHIP Empire Plan for plastic surgery coverage, you’ll probably spend a long time looking. Eventually, you may come across something that says some plastic surgery is considered cosmetic and is excluded from coverage. But if you look closely, you’ll also 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. 

When Is Plastic Surgery Covered by Insurance?  

Your NYSHIP Empire Plan may cover plastic surgery when a doctor determines that it’s medically necessary. Medical necessity is taken to mean that it will resolve a condition that wouldn’t otherwise be 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. The only permanent resolution to that pain would be breast reduction surgery, making that surgery a medical necessity.

Plastic surgery may also be covered for other reconstructive purposes. Survivors of cancer or other illnesses may have permanent scars or disfigurements as a result. Specifically, women who have had treatment for breast cancer with an unfavorable result, such as pain or deformity, can have medically necessary plastic surgery to fix those conditions In those cases, plastic surgery would be approved under the NYSHIP Empire Plan. 

In summary, if your plastic surgery is reconstructive or medically necessary, your NYSHIP Empire Plan may cover it. While it’s difficult to go into all the nuances involved in getting a surgery approved, the Empire Plan does have some guidelines for very common surgeries that you can use to help you understand your coverage.

NYSHIP Empire Plan Plastic Surgery Coverage at a Glance 

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

Here are a few procedures, traditionally deemed cosmetic, that are often approved for insurance coverage. 

Breast Reduction


Breast reduction, aka reduction mammoplasty, is a surgery to remove excess breast tissue and reshape and lift the breasts. Patients who have breast reduction often report reduced back pain, neck pain, headaches, and the resolution of skin conditions. This surgery will also have quality-of-life benefits such as improved ability to be involved in physical activities and body image. Breast reduction can also be used to create symmetry after someone has had a unilateral (single) mastectomy.

When it’s covered: Breast reduction surgery is considered medically necessary when patients have certain 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

Breast reconstruction involves using surgical techniques such as implants or natural tissue to rebuild the shape and fullness of the breast. Reconstruction surgery may also include tattooing to recreate the areola.

When it’s covered: Breast reconstruction is considered medically necessary after partial mastectomy or lumpectomy or total mastectomy, as mandated by New York state and federal laws. Reconstructive surgery is covered whether it’s related to cancer or was performed prophylactically to prevent it. Reconstructive surgery is also covered after breast conservation surgery, such as lumpectomy, when an asymmetry or breast deformity results.

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 is performed to correct these issues.

When it’s covered: If the initial breast reconstruction was covered by insurance, then the breast reconstruction revision is typically covered as well.

Mohs Reconstructive  Surgery


Mohs surgery is a procedure performed by a specialized dermatologist 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.

When it’s covered: This is pretty straightforward. Mohs reconstructive surgery is covered when Mohs surgery is covered. Your surgeon should work very closely with your dermatologist to make sure you get the best result. 

Rhinoplasty

 

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

When it’s covered: The deviated septum is a famous condition cited by starlets who don’t want to admit that they’ve had work done. However, it’s also accurate as far as medical necessity goes. If someone has severe airway obstructions due to a deviated septum or previous injury, rhinoplasty may be considered a covered 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 minimize the scar’s appearance.

When it’s covered: 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 was preventing 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 improve your quality of life in a meaningful way? That is what the insurance company is going to look at when they’re determining coverage for your care. Work with a provider who understands the ins and outs of medically necessary plastic surgery, and you’ll make the process a lot easier for yourself.

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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