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Insurance Coverage – Is It A Possibility?

Q:  Will my insurance cover this procedure?

A: While many procedures performed by G.D. Castillo, M.D. at Cosmetic Plastic Surgery Clinnic are solely cosmetic in nature, there are a number of procedures that may qualify for insurance coverage. For example, rhinoplasty or a “crooked nose deformity” may qualify for insurance coverage if it is performed to repair a deviated septum that is causing a blockage in the nasal passage for the patient.  Another procedure that may qualify is breast reduction if the patient is experiencing symptoms caused by the weight of the breasts, like back, neck or breast pain, difficulty with exercise, or interference with work duties. Upper blepharoplasty (eyelid surgery) may qualify for benefits if drooping skin is obscuring a patient’s vision.

The most important question for insurance companies is medical necessity – is there a medical reason for having this procedure, or is it solely being performed for aesthetic reasons?

Regardless of policy terminology, the insurance company Utilization Review Department’s determination of benefits will both begin and end on this basic question as defined by their own criteria.

Medical necessity often begins with proof that conservative medical treatment has been tried prior to a surgical recommendation and has not alleviated the problem.  With so many over-the-counter options available to the consumer today, many people are not reporting their symptoms and the frequency of their symptoms to their physician.  This lack of documentation can delay insurance eligibility since the background information as to conservative treatment is not documented within the patient record.  This is just one reason why it is important that patients communicate with their physician as to frequency of symptoms and response to the recommended treatment, including any over-the-counter remedies that the patient may be using.

As one example, a woman with large pendulous breasts may ask for a prescription or referral from her physician to have a bra constructed to help support the weight of her breasts to help alleviate her discomfort.  She should report any rashes or break down of her skin that may be caused by the size of her breasts as well as reporting the results of remedies she is utilizing, regardless if she is using a prescription medication or an over-the-counter product.  She should report any back or neck discomfort and be checked for postural difficulties and shoulder strapping (grooves or indentations in the shoulders caused by the weight of the breasts supported by bra straps).

If you believe that you have a condition that would be helped by a procedure that may qualify as medically necessary, you can call your insurance company’s benefit department and ask them to inform you of the coverage available in your specific policy, and further, to send you, in writing, their exact criteria for determining medical necessity for that procedure.  I’ve seen cases over the last 14 years where a few months of well-documented, failed conservative treatment has made the difference in obtaining insurance benefits for permanent surgical relief.

A consultation with Dr. Castillo at Cosmetic Plastic Surgery may be all that’s necessary to determine if insurance reimbursement is a possibility.  These consultations are available in both our Savoy and Bloomington, Illinois offices.

It’s well worth the effort!

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