Elective surgery, selective coverage

Elective surgery, selective coverage

Joseph Segen

Medically necessary. Insurers and health plans have long relied on that criterion in deciding whether to authorize or deny coverage of a particular treatment. So what happens to requests for procedures or services that are clearly not vital to the health of the enrollee–a hair transplant, tummy tuck or vasectomy, to name a few?

Although such procedures are sometimes called elective, a clear distinction must be made between surgery that’s medically unnecessary and surgery that is elective only in the sense that it’s a non-emergency–and the patient and doctor can have some input into the timing. Thus, the American Academy of Cosmetic Surgery uses the term “select procedures” to encompass the chemical peels, breast augmentations, rhinoplasties (nose jobs) and the like that are its stock-in-trade.

As society ages, such procedures are increasingly common: The AACS reports a 21 percent overall growth rate from 1994 to 1996 alone. Cosmetic surgery for men is helping to drive up the numbers: While females underwent fewer procedures, an increase in cosmetic surgery among men more than made up the difference.

Whatever the numbers, the question remains: Who pays? For purely cosmetic procedures it’s usually the patient. A survey of more than 300 HMOs conducted by the American Association of Health Plans found that a mere 12 percent covered cosmetic surgery.

But it’s not always clear where to draw the line. Is a voluntary sterilization in the same category as a tummy tuck? How about photorefractive keratectomy (PRK), a relatively new procedure to correct nearsightedness? Or a breast reduction performed to alleviate shoulder or back pain?

In fact, PRK, which costs about $2,000 per eye, is rarely covered, while a breast reduction deemed medically necessary may be.

A recent court case hammers home a related issue for benefits managers to worry about: If a plan does not cover a cosmetic or otherwise medically unnecessary procedure, who picks up the tab for care needed because of complications from the original surgery? The answer: Put it in the contract.

The case involved an enrollee in the PCA Family Health Plan who underwent–and paid for–elective cosmetic surgery performed in the surgeon’s office. The patient then developed complications serious enough to require hospitalization, and the hospital sued both the patient and PCA for reimbursement. The HMO stood firm, pointing out that the contract clearly stated that neither cosmetic surgery nor treatment for ensuing complications was covered. A Florida appeals court agreed, and held the patient responsible for the bill.

Where does reproductive surgery fit into this mix? While not exactly medically indicated, preventing unwanted pregnancy is a serious health issue–and picking up the tab for vasectomy and tubal ligation is likely to save purchasers and payers money in the long run. Not surprisingly, coverage for sterilization is nearly universal, at 97 percent for vasectomy and 98 percent for tubal ligation, according to the Kaiser Family Foundation.

Coverage is sporadic for reproductive assistance, especially the high-tech (and high cost) techniques. Helen Darling, manager of international compensation and benefits for Xerox, says her firm’s benefit package extends to in vitro fertilization (averaging $7,800 for one cycle) as well as sterilization, but excludes reverse sterilization procedures.

Breast surgery raises other questions, primarily about the reason for it. Richard Coorsh, a spokesman for the Health Insurance Association of America, says breast reconstruction associated with cancer is not considered cosmetic and is almost always paid for. Yet eight out of 10 physicians surveyed by the American Society of Plastic and Reconstructive Surgeons recalled having as many as 10 breast cancer patients who had been denied coverage for reconstructive surgery in the past year alone.

Cosmetic surgery on the rise

Procedure 1996 1990

Breast augmentation 76,630 44,440

Chemical peel 556,280 64,890

Facelift 48,940 36,980

Hairtransplant/restoration 244,470 57,710

Liposuction 292,940 71,632

Tummy tuck 10,330 6,860

Source: American Academy of Cosmetic Surgery, 1997.

The author is a physician based in Manhasset, N.Y.

COPYRIGHT 1997 A Thomson Healthcare Company

COPYRIGHT 2004 Gale Group