Do Any Health Insurance Companies Cover Elective Procedures?

by Steve Lander
Asking for surgery doesn't make it unnecessary.

Just because a procedure is elective doesn't mean that it won't be covered by your health insurance plan. The general category of elective procedures is very broad and encompasses everything from cosmetic surgery to many orthopedic procedures. For many insurers, the standard isn't whether or not a surgery is elective -- it's whether or not it's medically necessary.

Beyond the Nose Job

While the term "elective surgery" might bring up images of a LASIK machine fixing your eyes or a plastic surgeon making your nose smaller, plastic and refractive surgeries are just a few types of elective surgeries. Having a pacemaker installed or having an artery cleaned through angioplasty is also elective. Knee replacements, shoulder repairs and spinal stenosis surgeries are, as well. Finally, birth control and gynecological surgeries and exploratory surgeries -- such as those done to biopsy internal tissues to look for cancer -- also fit into this camp.

Can I Please, Please PLEASE Have Surgery?

One of the key factors in elective surgery is talking to your insurance provider before you have the procedure done. Since the surgery is elective, you have the time to confirm that you're covered for it. In addition, you may need to get pre-authorization for it to be covered at all, even if it is a medically necessary procedure. Furthermore, you can also find out what your out-of-pocket expense might be.

When Medical Necessity Strikes

While every insurance plan is different, it's generally safe to assume that a pacemaker will probably be covered, while a face-lift probably won't be. However, even seemingly medically unnecessary procedures may be covered when they have a functional purpose. For instance, women who have breast reduction surgery due to neck or back pain may have their treatment covered. Tummy tucks have been covered for bariatric surgery patients that experience irritation or fungal infections under the folds of skin that can form after rapid and permanent weight loss, as well.

Contraceptive Surgery

The women's health provisions under the Patient Protection and Affordable Care Act of 2010 require insurers to not only cover contraceptive surgery -- like tubal ligations -- for women, but also to cover it with no out-of-pocket cost. This rule only applies to plans that were issued after August 1, 2012 and has no impact on "grandfathered" plans. However, a survey conducted by the Society for Human Resources Management indicated that around 90 percent of large companies expect their plans to eventually lose their grandfathered status.

About the Author

Steve Lander has been a writer since 1996, with experience in the fields of financial services, real estate and technology. His work has appeared in trade publications such as the "Minnesota Real Estate Journal" and "Minnesota Multi-Housing Association Advocate." Lander holds a Bachelor of Arts in political science from Columbia University.

Photo Credits

  • BananaStock/BananaStock/Getty Images