Using Empire Plan benefits to cover plastic surgery is not a topic a lot of people are familiar with. What I usually see is people mistaking plastic surgery for cosmetic surgery, which just about all health insurance policies exclude. But plastic surgery isn’t always cosmetic. Sometimes, it’s medically necessary. Insurance companies have some criteria for how they define the difference. I deal with this frequently when helping our patients get Empire Plan benefits to cover plastic surgery at our office. Here’s what you need to know.
When Is Plastic Surgery Medically Necessary?
We talk about medical necessity a lot when it comes to plastic surgeries. Very broadly, medical necessity means that a patient suffers from a covered condition that can only be improved through surgery. But there are a lot of nuances to that. In just about all cases, the insurance company will have very specific criteria to define “medically necessary” as it relates to a plastic surgery procedure.
Breast reduction surgery is a great example. A doctor may believe that a patient’s breast reduction surgery is medically necessary to resolve a chronic pain condition. They may have a well-documented history, complete with treatment records going back years for neck pain related to their large breasts. A doctor would say that breast reduction surgery is medically necessary, but the insurance company wouldn’t necessarily agree.
That’s because their goal is to make the approval process objective. They need hard numbers or questions they can answer with a yes or a no. In the case of the breast reduction example, a reviewer will specifically look at the expected amount of breast tissue to be removed, compared to the patient’s body mass. These numbers are reviewed on something called the Schnur sliding scale, a listing of figures that represent high breast tissue-to-body surface area ratios. If the amount of breast tissue expected to be removed doesn’t fall within this scale, then the insurance company might not consider it medically necessary.
There are quite a few plastic surgery procedures with unique criteria like that. At Harris Plastic Surgery, we see five come up pretty regularly that are often covered by Empire Plan benefits.
Plastic Surgeries Often Covered by Empire Plan Benefits
Every plastic surgery covered by Empire Plan benefits will have to meet both subjective and objective criteria. Pain is a good example of subjective criteria, as it differs from person to person. Insurance companies often include objective criteria in their policies to determine if something’s medically necessary in more black-and-white terms. We see that in five surgeries that we frequently handle with the Empire Plan.
|Under the Women’s Health and Cancer Rights Act (WHCRA) of 1998, as well as state laws, all reconstructive surgeries relating to mastectomies are covered.|
Revision Breast Reconstruction
|A revision breast reconstruction corrects poor results from a previously covered reconstruction and is also covered under the Women’s Health and Cancer Rights Act.|
Breast Reduction Surgery
|Objective criteria for breast reduction surgery are based on the Schnur sliding scale. This is a calculation of the anticipated amount of breast tissue to be removed in grams, compared to the overall body size of the patient.|
Scar Revision Surgery
|There are no clear objective criteria for scar revisions, as this is covered by a range of procedures. However, cancer-related scars and those with “documented evidence of significant functional impairment” are often covered.|
Mohs Surgery Reconstruction
|Mohs surgery reconstruction is necessary when a patient undergoes Mohs surgery for facial skin cancer.|
Keep in mind that the above are only the objective criteria for using Empire Plan benefits to cover plastic surgery. They are the questions that can be answered with a simple yes or no. But other considerations are far more subjective. All this information is reviewed during the preauthorization.
Understanding the Insurance Preauthorization Process
Following your consultation with your plastic surgeon, you should meet with a patient coordinator who will walk you through the Empire Plan preauthorization steps. Preauthorization is usually required when surgery is elective and not done on an emergency basis. The surgeon’s office will connect with the insurance company to get their approval before they complete the procedure. While the specific steps to preauthorization will change based on the language in your policy as well as who administers it, this is what they usually look like.
1. Quote and request
The surgeon’s office submits a proposed surgical plan as well as statements of medical necessity, clarifying why the surgery is needed and should be covered. They will include notes from your treatment, their recommendations, and other pertinent details to open a claim and help make a determination.
The claim is submitted to a representative of the insurance company who will request further documentation as needed. Typically, they’ll seek out things like doctor’s notes, exams, imaging, and other information that shows evidence of treatment. The insurance company may refer to this process as a utilization review. In this, someone with medical expertise, very often a nurse, will review this information to determine whether it meets the medical necessity standards under the insurance policy.
3. Approval or appeal
In the most straightforward cases, the insurance company will approve the surgery without further evidence needed. However, in some cases, it will be denied at first, and additional documentation will be needed to appeal the decision. A denial is not always a permanent refusal of coverage. In some cases, it’s triggered by a misunderstanding of the purpose of the surgery, or just clicking the wrong button. Sometimes, it can be reversed by submitting additional proof or correcting the claim.
4. Patient contribution estimate
Anyone who’s ever used their insurance knows that “covered” does not mean in full. The patient will have to contend with copays, coinsurance, and deductibles.
- Copays: This is a flat rate paid per visit, usually $25 for Empire Plan.
- Co-insurance: This is the percentage of the allowed amount the patient is responsible for.
- Deductible: This is the dollar amount you must spend out-of-pocket before insurance begins covering care. Not all care applies to the deductible, and the deductible does not apply to all care.
During your initial consultation, the patient care coordinator will go over how these costs will apply to your specific surgery. They may complete this estimate based on tentative approval so you can get a good idea of your out-of-pocket costs upfront. That’s because the actual insurance approval process can take time.
Depending on the relationship between the practitioner’s office and the specific insurance company, it can take anywhere from several days to a month. At Harris Plastic Surgery, we are typically able to gain approval in under a week. That’s due to our understanding of the process and our deep knowledge of the insurance industry.
Once the approval is obtained and the patient knows exactly how much they’re expected to pay out-of-pocket, the surgery can be scheduled. When it’s complete, the doctor’s office will submit the pre-approved charges.
That’s a relatively simple explanation of how it works when using Empire Plan benefits to cover plastic surgery. Your doctor’s opinion and your insurance company’s opinion may differ on what medical necessity is. Your patient care coordinator is the person who’s going to help make that connection so you can submit the right information for approval.
Bringing Patient Advocacy to Breast Reduction and Reconstruction
At Harris Plastic Surgery, every consultation includes a thorough evaluation of your Empire Plan coverage for breast reduction surgery. We take a concierge approach to treatment, which includes working to minimize your out-of-pocket costs. 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.