Empire Plan Elective Surgery Coverage: Medically Necessary vs. Cosmetic

Breast reconstruction surgery—as pictured above—frequently falls under Empire Plan elective surgery coverage because it is medically necessary per NY state and federal laws.

I’m not a big fan of the term elective surgery because it’s pretty misleading. Elective surgery can still be entirely necessary for a patient’s quality of life and physical well-being. I also see a lot of people confuse it with cosmetic surgery. But while cosmetic surgery is elective, not all elective surgery is solely cosmetic. Empire Plan elective surgery coverage might be available if you have a condition that makes a procedure medically necessary.

Cosmetic vs. Medically Necessary Surgery

“Elective surgery” is a misleading term because it makes it sound optional. Elective simply means that the surgery can be scheduled in advance and that there’s no threat to the patient’s life by delaying it. An elective surgery can still be deemed medically necessary—meaning that it also might qualify for Empire Plan coverage.

What people often think when they hear elective is cosmetic. However, the two are not the same. Here is a brief breakdown of the differences:


Medically Necessary

A cosmetic procedure is based on aesthetics. It will not improve function in any significant way, though it may boost the patient’s self-esteem and improve their overall appearance. An example of a purely cosmetic surgery would be an abdominoplasty—a tummy tuck—as it’s strictly done to make the stomach appear flatter and more toned. It’s not likely that such a procedure would be covered under Empire Plan.

A medically necessary surgery is done to improve function in some way, eliminate a chronic condition, or enhance the patient’s quality of life. While there may be some cosmetic benefits to medically necessary plastic surgery, those are secondary to the overall goal. The overall goal is to improve the patient’s health. An example of medically necessary plastic surgery would be a woman getting breast reconstruction after a mastectomy due to cancer. This is considered medically necessary by NY state and federal law. Insurance companies are required to cover these procedures.

The distinction between cosmetic and medically necessary procedures is really important because it’s what Empire Plan elective surgery coverage is based on. Is your plastic surgery cosmetic, or is it of medical necessity? While the call is always made on a case-by-case basis, there are a few elective plastic surgery procedures that fall under Empire Plan coverage.

5 Empire Plan Elective Surgery Coverage Possibilities

I refer to these five Empire Plan elective surgery coverage options as “possibilities” because they are just that—possibilities. Whether Empire Plan will allow coverage for your elective plastic surgery will depend on the specific conditions of your case. I have found that five conditions are frequently considered medically necessary.

1. Breast Reconstruction

Breast reconstruction is possibly the most commonly covered Empire Plan elective surgery because—as I mentioned above—insurance plans are required to cover it under the Women’s Health and Cancer Reconstruction Act, a federal law enacted in 1998. The law mandates coverage for when mastectomies are performed to remove cancer or prophylactically—to protect against it.

The advancements we’ve made in the breast reconstruction field since that law was passed are pretty impressive. One surgery that draws a lot of Empire Plan patients to our office is our direct-to-implant reconstruction. In many cases today, we’re able to do a direct-to-implant procedure where your permanent implant is placed at the same time as your mastectomy. This is appealing to individuals who’d like to get the surgery out of the way in one fell swoop.

Empire Plan will typically cover procedures related to a covered medical condition. An Empire Plan plastic surgeon can help determine the best course of action.

2. Revision Breast Reconstruction

A revision breast reconstruction is also considered medically necessary to correct a poor result from a previously covered reconstruction. This is covered under the same law that breast reconstruction is covered under.

A patient may suffer a suboptimal result when there’s a deformity, asymmetry, nipple displacement, and depressions in the skin.

Such procedures are considered part of the original reconstruction covered under federal law. We have a lot of patients who are unaware of that or are confused by whether or not their reconstruction—with which they are dissatisfied—would qualify for revision.

The only way to know is to ask. Consulting with a doctor that specializes in revision breast reconstruction will help you determine if your surgery will be covered.

3. Breast Reduction

The medical necessity of breast reduction surgery—sometimes called reduction mammoplasty—is a bit less straightforward than that of reconstructive surgery. Many women want to get their breasts reduced for aesthetic reasons, but there are also medically necessary indications for doing so.

For example, women with large breasts often suffer from neck and back pain. The weight of their breasts pulls on their upper body and chest wall, causing them to hunch and put pressure on the vertebrae and discs in the cervical and thoracic parts of the spine. Treatment for someone with problems in their neck and upper back is commonly based on physical therapy, posture correction, medication, or sometimes even injections to block the pain. That may work for someone who has suffered an injury that will resolve. For a woman with large breasts, all the efforts from that treatment will continually be disrupted by the weight on her chest. If the only way to permanently resolve that pain is to complete a breast reduction, then it is medically necessary.

If it’s approved as medically necessary, then Empire Plan will cover whichever type of procedure you and your plastic surgeon determine is best in your case.

4. Mohs Surgery Reconstruction

Mohs surgery is a type of surgery used to treat facial skin cancer. When cancer is detected, a specialized dermatologist goes in and begins to remove it layer by layer. They continue to do this until there is no cancerous tissue remaining. Such surgery can go pretty deep and result in a scar or even facial deformity for the patient.

Mohs surgery reconstruction teams a plastic surgeon with that dermatologist. The plastic surgeon follows the dermatologist, closing their incisions in a way that limits tension and reduces scarring and distortion.

The medical necessity of this surgery is pretty straightforward as well. If someone needs a Mohs surgery, then their reconstruction would likely be considered medically necessary by their Empire Plan.

5. Scar Revision

Scar revisions can be tricky when it comes to medical necessity because in many cases, it is considered cosmetic.

Scar revision surgery is medically indicated if it could significantly improve someone’s ability to function. Someone who has a deep scar on their cheek, for example, may struggle to close their mouth all the way. Scar revision surgery would remove the tension in that scar to allow the mouth to return to normal. Revisions may also be covered to correct scarring from cancer treatments.

Empire Plan elective surgery coverage extends to many of the surgeries listed above and quite a few others as well. The only person who can make the determination of medical necessity for an elective procedure is a doctor. If you believe that elective surgery might be medically necessary for you, then it’s smart to schedule a consultation to get more information.

Bringing Patient Advocacy to Breast Reduction and Reconstruction

At Harris Plastic Surgery, we are very familiar with Empire Plan elective surgery coverage due to our expertise in breast reduction and reconstruction as well as Mohs surgery and scar revision. If you would like to schedule a consultation, please contact us.

Stephen U. Harris, MD FACS

Dr. Stephen U. Harris is a board-certified cosmetic surgeon and recognized expert in breast reduction and reconstruction surgeries, having performed thousands in his career. When it comes to patient care, his philosophy is that every surgery should improve his patient’s overall quality of life, not just their appearance. Dr. Harris stays up-to-date on all the latest advancements in breast augmentation, reconstruction, and reduction and is a recognized innovator in the field. In fact, he was the first surgeon at Good Samaritan Hospital to offer primary prepectoral implant breast reconstruction, as well as secondary prepectoral revision surgery.

Dr. Harris also serves as Chief of Plastic Surgery at Good Samaritan Hospital in West Islip, New York and is an active staff surgeon (and former Chief of Plastic Surgery) at South Shore University Hospital in Bay Shore, New York.

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