Insurance says my procedure is 'cosmetic' but I need it medically — what now?
Plans frequently misclassify medically necessary procedures as cosmetic. Many are appealable.
Common 'cosmetic' misclassifications include: bariatric surgery (NOT cosmetic), gender-affirming care (NOT cosmetic — and ACA §1557 protects against this), reconstructive surgery after mastectomy (federally required under Women's Health and Cancer Rights Act), corrective rhinoplasty for breathing problems, dermatologic procedures for skin cancer or precancers.
Steps
- Get the chart documenting the medical (not cosmetic) reason
- Cite the relevant specialty-society guideline supporting the procedure for your indication
- For gender-affirming care, cite ACA §1557 nondiscrimination
- For mastectomy reconstruction, cite the Women's Health and Cancer Rights Act (federal requirement)
- File internal appeal, then external review
Frequently asked questions
Insurance says my procedure is 'cosmetic' but I need it medically — what now?
Common 'cosmetic' misclassifications include: bariatric surgery (NOT cosmetic), gender-affirming care (NOT cosmetic — and ACA §1557 protects against this), reconstructive surgery after mastectomy (federally required under Women's Health and Cancer Rights Act), corrective rhinoplasty for breathing problems, dermatologic procedures for skin cancer or precancers.
What are the steps?
1. Get the chart documenting the medical (not cosmetic) reason; 2. Cite the relevant specialty-society guideline supporting the procedure for your indication; 3. For gender-affirming care, cite ACA §1557 nondiscrimination; 4. For mastectomy reconstruction, cite the Women's Health and Cancer Rights Act (federal requirement); 5. File internal appeal, then external review
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