Empire State health insurers may not have to pay for liposuction or ordinary nose jobs, but they should pay for plastic surgery that is medically necessary.
The New York State Insurance Department has tried to make that point in new regulations adopted on an emergency basis.
In the regulations, department officials try to spell out when health insurers can automatically deny requests for plastic surgery and when they must consider arguments about medical necessity.
Officials have put requests for coverage for skin peels, hair transplants, correction of inverted nipples, ear piercing and minor work on the tip of a patient’s nose on a long list of procedures that can trigger automatic denials.
But “a claim or request for coverage of reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child that has resulted in a functional defect shall not be considered by a health plan to be cosmetic,” according to the text of the new regulations. “Reconstructive surgery may however be reviewed for medical necessity.”
Health insurers worked with state regulators to develop the new regulations, New York officials write in a notice explaining why the department developed the regulations.
Adopting the regulations is “necessary to establish uniformity among health plans and ensure that cosmetic surgery denials are given the appropriate review,” officials write in the notice.
Links to the text of the new regulations and other documents relating to the regulations are on the Web at Document Link