A “mommy makeover” refers to a combination of surgeries that women often undergo to restore their pre-pregnancy body. The procedures typically target the breasts, abdomen, and sometimes the lower body to address issues such as sagging breasts, stretched skin, and excess fat.
While many women choose a mommy makeover for purely aesthetic reasons, in some cases, certain procedures are considered medically necessary. In these instances, surgery is covered by health insurance plans, including the New York State Health Insurance Program (NYSHIP). Getting your mommy makeover covered by NYSHIP might not be as difficult as you think.
When Is a Mommy Makeover Medically Necessary?
A Mommy Makeover, which can include abreast reduction and abdominal contouring, may be considered medically necessary, rather than purely cosmetic – if the procedures address significant health concerns. Medical necessity is typically determined based on the criteria listed in the table below.
Medical Necessity of Mommy Makeover Procedures | |
|---|---|
Procedure | Medically Necessary If: |
Breast Reduction |
|
Tummy Tuck (Abdominoplasty) |
|
Steps for NYSHIP Coverage
To be considered for coverage by NYSHIP, patients must typically take steps to demonstrate the medical necessity of their procedures. This includes providing thorough documentation from healthcare providers – such as a primary care physician, plastic surgeon, or other specialist – that outlines the severity of physical complications and how they affect your ability to lead a normal life. In most cases, you’ll be required to try less invasive treatments before your insurance will approve surgery.
Consult with a Board-Certified Plastic Surgeon
- Choose a surgeon who specializes in medically necessary procedures.
- They will assess whether your symptoms qualify for insurance coverage.
Obtain Medical Documentation
- Keep records of chronic pain, infections, skin irritation, posture issues, or functional limitations.
- Get evaluations from your primary care physician, physical therapist, dermatologist, or orthopedic specialist to support your claim.
Try Non-Surgical Treatments First
- Insurance often requires proof that you’ve attempted non-surgical treatments such as:
- Physical therapy.
- Pain management.
- Prescription creams or medications for rashes/infections.
- Supportive bras or compression garments.
Submit Pre-Authorization to Insurance
- Your surgeon’s office will submit a letter that details medical necessity, including:
- Symptoms and impact on daily life.
- Photos documenting skin irritation, asymmetry, or posture issues.
- Evidence of failed non-surgical treatments.
Follow Insurance Guidelines
- Check your policy for specific requirements, such as:
- Minimum amount of breast tissue to be removed (breast reduction).
- BMI or weight stability requirements.
- Length of time your symptoms have persisted.
Appeal If Denied
- If your insurance denies coverage, work with your surgeon’s office to appeal the decision by providing additional documentation or seeking a second opinion.
No Surprise Act – Insurance Coverage for Out-of-Network Providers
For hospital-based surgeries, patients now have a new avenue for getting insurance to reimburse their surgeon of choice with less out-of-pocket expenses. The No Surprise Act (Section 2799B-3 of the Public Health Service Act) means you don’t have to pay more for surgery with an out-of-network provider than you would for the same surgery in-network. This means the fees you will pay including costs like co-payments, co-insurance, and your normal deductible are limited to the in-network cost sharing for the provider.
While this involves a little more behind-the-scenes paperwork from your plastic surgeon’s office, at Harris Plastic Surgery, we are happy to take those extra steps to make sure you can have the surgery you want at a fair price.
Getting Your Mommy Makeover Covered by NYSHIP
While a mommy makeover is often viewed as a cosmetic procedure, some procedures may be covered as medically necessary for women who experience significant physical complications as the result of pregnancy and childbirth. When they are deemed medically necessary, NYSHIP covers some components of a mommy makeover, including breast reduction for chronic pain, and tummy tuck surgery for umbilical hernias. Equipped with the right documentation and medical justification, you may be able to achieve both the aesthetic and physical relief you want, without paying for everything out-of-pocket!
Harris Plastic Surgery - Your Breast Reconstruction Experts
Have you been wondering about getting your mommy makeover covered by NYSHIP? Reach out to our office today to schedule your consultation and find out. You can also contact us by phone/text if you have any additional questions for our team.
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.
