Jeffrey Wade
Whether a surgery is covered by insurance depends on several factors, including the type of insurance and whether the procedure is deemed medically necessary. Many health insurance plans cover surgical procedures that are considered 'medically necessary' by a healthcare professional. Medicare, for example, covers many medically necessary inpatient and outpatient surgical procedures. However, the definition of medically necessary can vary between insurance providers, and some plans may have specific requirements or exclusions. It's important to carefully review your insurance plan's coverage details and consult with a healthcare professional to determine if a surgery is likely to be covered.
| Characteristics | Values |
|---|---|
| Definition of 'medically necessary' | Services or supplies that are needed to diagnose or treat a medical condition and that meet accepted standards of medical practice |
| Criteria for 'medically necessary' | - Treats or diagnoses an illness, injury, deformity, disease, or significant symptoms such as severe pain |
| - May be required for the body to function as intended | |
| - Within the generally accepted standards of medical care in the community | |
| - Not solely for the convenience of the insured, the insured's family, or the provider | |
| Elective surgery | A procedure that the patient can choose to have or not have |
| Coverage for elective surgery | Depends on whether it is deemed medically necessary |
| Inpatient vs Outpatient | Inpatient care tends to be more involved and more costly, billed in two parts (facility fee and surgeon fee) |
| In-network vs Out-of-network | In-network providers offer discounted rates, so patients pay less for copays, coinsurance and their out-of-pocket maximum |
What You'll Learn
- Purely cosmetic procedures are not covered by insurance
- Surgeries deemed 'medically necessary' are often covered
- Inpatient surgeries tend to be more expensive than outpatient ones
- Short-term health insurance covers surgeries for unexpected illnesses or injuries
- Medicare covers many medically necessary inpatient and outpatient surgical procedures
Purely cosmetic procedures are not covered by insurance
However, there are some cases in which cosmetic surgeries may be deemed necessary for health or functionality and, therefore, covered by insurance. For example, a blepharoplasty, or eyelid lift, may be partially covered by an insurance company if excess eyelid skin is impairing a patient's vision. Similarly, a panniculectomy, or excision of excess skin on the lower abdomen, may be covered by insurance if the hanging skin is causing chronic skin rashes, irritation, infections, or impaired mobility.
In the United States, the American Medical Association (AMA) has provided definitions of 'cosmetic surgery' and 'reconstructive surgery' that are used by health insurance companies to determine coverage. Cosmetic surgery is defined as a procedure performed to reshape normal structures of the body to improve the patient's appearance and self-esteem. On the other hand, reconstructive surgery is defined as a procedure performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumours, or disease.
While these definitions provide a clear distinction between cosmetic and reconstructive surgery, there is still some grey area. Many procedures have both an aesthetic and functional purpose. For example, a rhinoplasty, or nose job, can be performed to improve the shape of the nose, but it can also correct a deviated septum, which can cause breathing issues. In such cases, insurance may cover the portion of the surgery that addresses the functional issue, while the patient would need to pay out of pocket for the cosmetic aspect.
Ultimately, whether or not a specific procedure is covered by insurance depends on the individual case and the insurance provider's determination of medical necessity.
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Surgeries deemed 'medically necessary' are often covered
Surgeries deemed medically necessary are often covered by insurance, but the definition of "medically necessary" can vary between insurance companies and health plans. Medicare, for example, covers many medically necessary inpatient and outpatient surgical procedures.
A surgery is typically deemed medically necessary if it treats or diagnoses an illness, injury, deformity, disease, or significant symptoms such as severe pain. It may also be required for the patient's body to function as it should or as close to that as possible. For example, a patient with severe knee arthritis who is unable to get up and down the stairs may require a knee replacement. This surgery would be medically necessary as it would allow the patient's knee to function as intended.
In some cases, cosmetic surgeries may also be deemed medically necessary. For instance, a patient with excess eyelid skin that droops into their field of vision may require a blepharoplasty, or eyelid lift, to improve their vision. Similarly, a panniculectomy, or excision of excess skin on the lower abdomen, may be necessary for patients who have experienced significant weight loss and are now suffering from impaired mobility or chronic skin issues.
It is important to note that the determination of whether a surgery is medically necessary is made by the insurance company or health plan, and their opinion may differ from that of the surgeon. If a health plan does not deem a surgery to be medically necessary, it is unlikely to be covered. However, there is typically an appeals process that can be utilized if there is a disagreement.
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Inpatient surgeries tend to be more expensive than outpatient ones
When it comes to surgical procedures, there are two main types: inpatient and outpatient surgeries. Inpatient surgery requires at least one overnight stay in the hospital for recovery, whereas outpatient surgery allows the patient to return home on the same day without the need for an overnight stay. The distinction between these two types of surgeries lies not only in the length of the patient's stay but also in their complexity and cost.
The rise of ambulatory centres and advancements in technology have contributed to the increase in outpatient surgeries. These procedures are usually less complex, require shorter recovery times, and can be performed with greater precision, sometimes even with robotic assistance. The reduced complexity and shorter recovery times of outpatient surgeries also mean that they tend to have shorter wait times compared to inpatient procedures.
While inpatient surgeries may be necessary for more complex or invasive procedures, outpatient surgeries offer a cost-effective and convenient alternative for many patients. The lower cost of outpatient surgeries is a significant advantage, and this is often due to the absence of overnight stays and the use of specialised clinics or surgical centres.
It is worth noting that the cost of surgery can vary depending on several factors, including the complexity of the procedure, the type of anaesthesia used, the location of the surgical facility, and the surgeon's experience and reputation. However, the distinction between inpatient and outpatient surgeries remains an essential factor in determining the overall cost of a medical procedure.
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Short-term health insurance covers surgeries for unexpected illnesses or injuries
Short-term health insurance is a good option for those who need quick coverage for a limited time, such as when facing a lapse in coverage due to losing a job, waiting for Medicare eligibility, or waiting for the Open Enrollment Period to begin. These plans are not meant to be long-term solutions and typically last between three and twelve months, with the possibility of renewal up to three times, depending on the state. They are also more affordable than long-term plans, with individuals paying as little as $55 per month.
Additionally, short-term plans may not offer coverage for services like maternity, mental health, and preventative care, and they don't include all routine medical needs. They also don't cover pre-existing conditions or maternity coverage. Therefore, it's essential to carefully review the specifics of the short-term plan, as they can vary from policy to policy.
When considering short-term health insurance, it's important to be aware of the cons, such as the possibility of being denied coverage for pre-existing conditions and the lack of coverage for certain services. Additionally, short-term plans may not be renewable, and they are not available in all states.
Short-term disability insurance (SDI) is another option to consider when facing surgery. It provides income replacement during recovery and can be obtained through an employer-sponsored plan or a private insurance firm. SDI typically covers a percentage of your pre-disability income, and the benefits usually last for three to six months.
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Medicare covers many medically necessary inpatient and outpatient surgical procedures
Medicare covers a wide range of medically necessary inpatient and outpatient surgical procedures. This includes emergency surgeries, such as operations for life-threatening conditions or serious injuries, as well as scheduled procedures like joint replacement or tumour removal.
Medicare Part A covers inpatient surgeries, while Medicare Part B covers outpatient operations. After meeting the deductible, Original Medicare pays for 80% of medically necessary surgeries, with the patient responsible for the remaining 20%. For outpatient surgeries, patients pay 20% of the Medicare-approved amount for their doctor's services, as well as a copayment for each service received in a hospital outpatient setting.
Medicare Advantage plans can provide additional coverage, often including Part D, vision, hearing, and dental. These plans also have an annual out-of-pocket limit on healthcare spending, which can reduce costs for surgeries over time.
It is important to note that Medicare does not cover all surgeries. Original Medicare, for example, does not cover elective operations that are not considered medically necessary, such as cosmetic surgeries, mole removal, or Botox.
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Frequently asked questions
Elective surgery is a procedure that a patient can choose to have or not have. It may be medically necessary or it may not be. Necessary surgery is required to treat or diagnose an illness, injury, deformity, disease, or significant symptoms such as severe pain.
Insurance will often cover elective surgery if it is deemed medically necessary. However, this definition can vary between insurance providers.
If your insurance claim is denied, you will be responsible for the entire bill. However, with any insurance plan, you have the right to appeal any denial. Your physician may also be able to advocate on your behalf to get the procedure approved.
Medicare defines 'medically necessary' as "Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice." It is used to describe the coverage offered by a health plan. Each insurance company has its own policies to identify what is considered a medically necessary service.
Review your insurance plan's Summary of Benefits and Coverage (SBC) to see what is considered a 'covered service'. Contact your insurance provider with your SBC and ask for a price estimate for your procedure. They may also have an online cost estimator tool.
