“This surgery is cosmetic, it cannot be claimed”
“This surgery is cosmetic; it is not reimbursable.”
“This procedure is for aesthetic purposes; insurance won’t cover it.”
These are real-world examples from clinical practice, demonstrating a misunderstanding prevalent among physicians, healthcare personnel, and insurance officers. Such misconceptions lead to inappropriate treatment of patients, such as denying medical benefits, refusing referrals to higher-level facilities, or denying private insurance claims. This article hopes to establish a correct understanding for the rightful benefit of patients.
All surgical treatments are performed with the hope of a good cosmetic outcome.
There is no task performed by a plastic surgeon that does not aim for a good cosmetic outcome. For example:
- Cleft lip repair: To this day, plastic surgeons worldwide continue to debate which techniques yield more beautiful results, innovating new methods to best recreate a natural philtral ridge and ensure the nose is aesthetically pleasing, among many other details.
- Secondary cleft repair: As patients grow, surgeons still strive to refine the nose for beauty, revise scars to be inconspicuous, and ensure full, natural lips—all of which are done for aesthetic improvement. In reality, the goal is to help the patient look as normal as possible.
- Cleft palate repair: Although it is inside the mouth and not visible to others, surgeons still strive for a beautiful result down to the uvula. Even for a minor asymptomatic fistula that does not cause speech or leakage issues, patients or parents often request surgery to ensure no hole remains.
- Alveolar cleft: Often involving displaced teeth, these patients can eat and speak normally, but their smile is affected. Treatment involves orthodontics and bone grafting. This is widely supported and reimbursable, even featuring in national projects like the "Beautiful Smile, Clear Voice" initiative.
- Skin cancer: There is a constant effort to find surgical methods that leave the skin and the affected area looking near-normal and beautiful after tumor removal. Physicians continue to compete to publish their aesthetic methods in medical journals.
- Craniosynostosis: Although the primary goal is to expand space for the brain, the aesthetic shape of the skull is never overlooked. Special helmets are marketed for infants to adjust head shape to normal, and 3D technology is used to design surgeries for optimal aesthetic results.
- Even positional or deformational plagiocephaly, which is not considered a disease, is treated by adjusting sleep positions or using expensive specialized helmets to ensure a normal head shape.
Even non-plastic surgeons treat diseases and abnormalities while hoping for a positive cosmetic outcome. For example:
- Polydactyly (Extra fingers): Whether at the thumb or pinky, even if it does not affect function or cause pain, it looks abnormal. Parents want it removed, and all doctors accept these cases for removal under medical coverage.
- Preauricular tags: These do not cause pain, inflammation, or cancer, and do not impact organ function, yet every doctor removes them, and they are covered by benefits.
- Breast cancer: Even when removing cancer, surgeons today prioritize beauty, avoiding total mastectomies where possible and using tissue transfers or implants to ensure the breast returns to a normal appearance.
- Amputation: No good surgeon performs an amputation carelessly; they must strive to ensure the remaining stump has a good, non-unsightly shape. Furthermore, patients receiving prosthetic limbs always desire those that look natural and attractive.
- Obstetrics: From previously using vertical midline incisions which were easier, surgeons have switched to low-level horizontal incisions so they can be hidden by clothing. Everyone desires a beautiful scar and the ability to show their abdomen.
It can be seen that a good cosmetic outcome is a desirable goal for both the patient and the physician in any surgical treatment. Surgeries aimed at a cosmetic outcome, as exemplified above, are almost entirely eligible for medical benefits or insurance claims.
Cosmetic Surgery vs Reconstructive Surgery
Surgery with the goal of changing a body part from abnormal to normal is called reconstructive surgery. When it is understood that a patient is receiving reconstructive surgery, there is no issue; it is reimbursable and eligible for benefits.
Surgery with the goal of changing a body part from normal to a different appearance is called cosmetic surgery or aesthetic surgery. It is universally understood that this is not reimbursable and not eligible for benefits.
(Read more about this in the article What is Plastic Surgery?)
It is clear that if a procedure is labeled as reconstructive surgery or cosmetic surgery, no one is confused.
Do Not Confuse Cosmetic Surgery with Cosmetic Outcome
By now, we should understand that there is confusion in the usage of the word "cosmetic." It is an adjective. If spoken without a following noun, one cannot know if it refers to cosmetic surgery or a cosmetic outcome.
Many people use English terms interchangeably, which confuses the speaker themselves. For instance, saying “This surgery is cosmetic; it cannot be claimed.” If the speaker means "cosmetic surgery," that is appropriate. But if they mean "this surgery has cosmetic outcome as a goal," then it is inappropriate. The problem is the speaker often does not know which they mean.
Saying “This surgery is done for beauty; insurance won’t cover it.” is not always correct. If the surgery aims to correct an abnormal body part to normal, it is reconstructive surgery. Even if it is done for "beauty" (cosmetic outcome), it is a positive and normal medical goal that should be reimbursable. Examples include microtia (absence of ear), traumatic ear loss, or nasal deformity after cleft repair, etc.
If asked “Please state the necessity for surgery,” the attending physician can answer truthfully based on whether it is reconstructive or cosmetic surgery. If it is reconstructive surgery, the answer should be along the lines of "Surgery to restore the (organ) to a normal appearance" or "Surgery to correct (organ) deformity due to (disease)." If it is cosmetic surgery, the answer is simply "There is no medical necessity, but the patient desires to change the appearance of the (organ)."