Are Cosmetic Facial Surgery Procedures Covered by Insurance?

Oral and maxillofacial surgery can be an expensive proposition, especially if your insurance company denies coverage for the procedure. It’s important to know how much you can expect to pay out-of-pocket in order to avoid costly post-op surprises.

Patients often ask whether cosmetic facial surgery will be covered by their policy—and the answer is: It depends. Use this simple guide to learn which factors most insurance providers use to determine coverage.

Please note that these are guidelines only. Always discuss billing/coverage with your oral surgeon and insurance company prior to undergoing surgery.

Cosmetic vs. Reconstructive

Defining whether your surgery is cosmetic or reconstructive plays a vital role in determining coverage. Most insurance companies follow the definitions given by the American Medical Association or the American Society of Plastic Surgeons:

  • Cosmetic surgery is the reshaping of normal body structures for the benefit of improved appearance and self-esteem.
  • Reconstructive surgery involves the correction of abnormal body structures. Abnormalities can be congenital/developmental defects or caused by trauma, infection, tumors or disease.

Reconstructive surgery that aims to correct or improve body function is the most likely to be covered, but surgery aiming to restore “normal” appearance may be partially or fully covered as well, despite its aesthetic nature.

Type of Insurance and Policy Tier

There are four basic types of medical insurance in the United States:

  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Point of Service Plan (POS)
  • Exclusive Provider Organization (EPO)

While one is not necessarily better/worse than another in terms of cosmetic facial surgery coverage, your insurance type will likely play a role.

More importantly, the tier of your plan will absolutely affect your level of coverage. Naturally, more expensive plans are more likely to pay for all or part of your cosmetic facial surgery.

Extenuating Circumstances

Insurance coverage is much less fixed than patients realize. As new treatments and procedures become available, how different surgeries are categorized is reevaluated. While your policy may not cover you today, it’s possible that you may be covered under the same policy at some point in the future.

Each patient’s personal history and needs also are taken into consideration, meaning that two patients with the exact same plan may not qualify equally for a given procedure.

Orthodontic Benefit

Oral and maxillofacial surgery coverage often comes down to whether or not the insurance company deems the procedure to provide sufficient “orthodontic benefit.”

Orthodontic benefit includes improving your ability to chew food, speak or breathe.

In many situations, your oral surgeon can make a case on your behalf to your insurance provider as to why a procedure is more medical in nature than cosmetic. Such a professional recommendation is never a guarantee, but it will improve your chances.