Using the NYSHIP Empire Plan for Plastic Surgery

For New York State employees, retirees, and their dependents, the NYSHIP Empire Plan is known for its broad national coverage and flexibility. But when it comes to plastic surgery, many patients are unsure what is covered, what is excluded, and how to navigate the approval process.

The short answer: purely cosmetic procedures are excluded, but plastic surgery that is medically necessary may be covered under the Empire Plan. This guide explains what patients need to know about using the NYSHIP Empire Plan for plastic surgery.

How to Know if Your Surgery is Covered by NYSHIP

Cosmetic surgery is defined as procedures performed solely to improve appearance without correcting a functional problem or medical condition, and is generally excluded under NYSHIP rules.

However, plastic surgery may be covered by NYSHIP if deemed medically necessary. Medical necessity typically means the procedure is required to:

• Correct a functional impairment
• Relieve chronic pain or physical symptoms
• Repair damage caused by trauma, cancer, or congenital conditions
• Restore normal form and function after illness or surgery

If a procedure meets medical-necessity criteria and is supported by proper documentation, the Empire Plan may provide coverage through its Medical/Surgical Program.

5 Plastic Surgeries Often Covered by the NYSHIP Empire Plan

Based on our experience helping hundreds of patients navigate their NYSHIP Empire Plan benefits, these five procedures are often covered:

Remember, meeting the objective criteria is just part of the equation. Subjective factors like documented pain, limited mobility, and treatment history all play important roles in your approval.

Using the NYSHIP Empire Plan for Plastic Surgery: Step by Step

Following your consultation with a plastic surgeon, a patient coordinator will walk you through the Empire Plan preauthorization steps. While the specific preauthorization steps vary by procedure and the language in your policy, here’s what the process generally looks like.

Step 1: Initial Quote and Documentation Request

Your surgeon’s office submits a detailed surgical plan to NYSHIP. This includes:

• Your doctor’s notes from consultations
• Explanation of medical necessity
• Photos (when relevant)
• Proposed surgical approach
• Expected outcomes

Step 2: Utilization Review

A medical professional at the insurance company (usually a nurse reviewer) examines your case. They’ll request additional documentation to verify medical necessity:

• Treatment history showing conservative measures were tried first
• Imaging results (X-rays, MRIs, etc.)
• Physical therapy records
• Medication logs
• Specialist notes

This review process ensures your case meets the NYSHIP Empire Plan’s specific criteria for coverage.

Step 3: Approval or Appeal

In straightforward cases, you may receive approval within days. But if your initial request is denied, this doesn’t mean the end of the road. Denials sometimes happen due to:

• Missing documentation
• Incorrect coding or paperwork errors
• Misunderstanding of the procedure’s purpose

You have the right to appeal and submit additional evidence, with the support of your surgeon’s office. Many initial denials are overturned once the reviewer can see the whole picture.

Step 4: Understanding Your Financial Responsibility

“Covered” doesn’t mean free. When using the NYSHIP Empire Plan for plastic surgery, you’ll still have:

• Copays: Typically $25 per visit for Empire Plan members
• Coinsurance: Your percentage of the allowed amount (usually 10-20% after your deductible is met)
• Deductible: The amount you pay before insurance kicks in (varies by plan tier)

During your consultation, our patient care coordinator will provide a detailed estimate to avoid surprises.

Step 5: Schedule Your Surgery

With approval in hand and a clear picture of your costs, you’re ready to schedule your surgery with us. The surgeon’s office will then submit pre-approved charges to the NYSHIP Empire Plan after your surgery is complete.

How Long Does NYSHIP Empire Plan Approval Take?

The timeline varies based on the complexity of your case and how quickly additional documentation can be gathered. In our experience working extensively with the NYSHIP Empire Plan, we typically obtain approval within one week. Our deep knowledge of NYSHIP’s specific criteria helps us submit complete documentation upfront, which speeds up the entire process.

Tips for Faster Approval When Using the NYSHIP Empire Plan for Plastic Surgery

• Start documenting early: If you’re considering breast reduction, for example, keep records of all treatments you try for pain relief, like physical therapy, pain medications, supportive garments, etc. Having six or more months of documentation makes your case a lot stronger.
• Get organized: Gather all relevant medical records before your consultation. The more complete the information we can submit initially, the faster your review will be.
• Ask questions: Your patient care coordinator is your advocate. Don’t hesitate to ask about specific criteria for your procedure or what documentation would strengthen your case.
• Be patient but persistent: If your case is denied initially, work with your surgeon’s office on the appeal. Additional documentation may make a difference.

Why Experience Matters When Using the NYSHIP Empire Plan for Plastic Surgery

At Harris Plastic Surgery, we’ve helped hundreds of New York State employees successfully navigate their NYSHIP Empire Plan benefits for breast reduction and reconstruction.

We understand the exact criteria Empire Plan reviewers look for, we know how to document your case thoroughly from the start, and we work to minimize your out-of-pocket costs while maximizing your chances of approval.

To learn more about using the NYSHIP Empire Plan for plastic surgery, reach out to our office to schedule your consultation. You can also contact us by phone/text.