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Elective Surgeries - What Elective Surgeries are Covered By Health Insurance?

Health Insurance Companies Will Cover Surgeries They Deem Medically Necessary -- And That Varies

By Maureen Salamon

Updated February 04, 2009

(LifeWire) - Emergency surgery that saves lives is clearly not optional. But elective surgery -- which often improves your quality of life, rather than saves it -- is, by definition, a choice, not a mandate. Because health insurance companies typically base their coverage decisions on the necessity of a procedure, this distinction becomes quite important when it's time to pay up.

Elective surgery is often perceived as strictly cosmetic, a procedure done only to improve a patient's appearance. But breast implants, face lift, liposuction and vision correction surgeries are only some of the operations considered optional. Elective surgeries also include hip replacements, cataracts, heart procedures such as implanting pacemakers and clearing arteries with angioplasty;and sterilizations such as vasectomies and tubal ligations.

In general, insurance companies will cover procedures they deem medically necessary. But what is judged medically necessary can vary from plan to plan.

Types of Elective Surgeries

According to the Centers for Disease Control and Prevention (CDC), more than 31 million outpatient surgeries are performed each year. The CDC does not distinguish how many of these operations are elective, but many might be considered so because they are not performed in an emergency setting.

Elective surgeries include:

  • Biopsies or exploratory surgery, which is used to diagnose an illness or determine how advanced it is.
  • Gynecological, which includes procedures such as hysterectomies (removal of the uterus and/or ovaries).
  • Musculoskeletal, to replace deteriorated joints.
  • Refractive, to repair vision defects; often referred to as LASIK, which is one form.
  • Plastic, including procedures to reconstruct breasts or other body parts affected by illness or injury.
  • Cardiovascular, which improves the heart's function.

Doctors may regard some of these surgeries -- while technically elective --  as key to improving your quality of life. Other procedures they may not.

Definition of Need Varies

Central to the distinction between elective and non-elective surgery is the definition of need. This definition affects insurance carriers' decisions to cover a procedure or deny a claim.

A patient might think that she needs breast reduction surgery, for example, to reduce the bodily pain and stress that can result from having large breasts, but her insurance company might disagree and refuse to pay for it.

Few, however, would judge a biopsy procedure to test for the presence of cancer as optional.

And breast implant surgery for cosmetic purposes that would not typically be covered often might be if it is related to reconstruction during breast cancer treatment.

Insurers' Guidelines Vary

Some insurance companies will cover a surgery that, while technically unnecessary, will save the company money down the line and perhaps avert an illness.

Some examples:

  • Vision correction, which negates the need for future eyeglass and contact lens prescriptions.
  • Sterilization, which negates the need for future birth control prescriptions or procedures.
  • Weight-loss surgery, which can help an obese person avoid future weight-related illnesses.
  • A nose job (rhinoplasty), which can correct breathing problems.

Find Out What Your Insurer Covers

How can you know for certain what your individual health policy covers? Ask.

You can check the coverage summary booklet that is provided by your insurer. If you don't have one, your insurer can supply you with one.

And you can get guidance from a plan representative. The numbers and addresses should be on your insurance card.

Paying for Surgery

If your insurance company balks at paying for elective surgery you think you need, be persistent. You can appeal its decision.

If the answer is still no, you might consider seeking a payment plan. Some doctors or medical facilities will let you finance elective surgeries, paying a portion up front and the rest over a period of time.

LifeWire, a part of The New York Times Company, provides original and syndicated online lifestyle content. Maureen Salamon is a New Jersey-based freelance writer whose work has appeared in a variety of online and print publications.

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