| HMO | Reconstructive/Cosmetic Surgery |
| Aetna US Healthcare | Covers: Surgeries to correct the results of injuries or congenital defects necessary to restore normal bodily functions including but not limited to cleft lip and cleft palate. Also covers breast reconstruction following mastectomy.
Excludes: Cosmetic surgery such as ear piercing, rhinoplasty, lipectomy, and surgery or treatment relating to the consequences or as a result of cosmetic surgery other than medically necessary services. Also excludes treatment of gynecomastia (abnormal enlargement of male mammary glands) and augmentation or reduction mammoplasty. |
| Blue Cross Blue Shield | Covers: Reconstructive breast surgery following a mastectomy. Coverage includes the surgery and reconstruction of non-diseased breast and prosthesis. Also covers surgeries for cancer and to correct congenital defects for children. This includes treatment and care of children born with cleft lip or cleft palate.
Limits: Prior approval is required. Excludes: Cosmetic Surgery, except when necessary to correct condition resulting from trauma or accidental injury that occurred when member enrolled in BCBS. |
| CIGNA / Healthsource | Covers: Reconstructive breast surgery following mastectomy. Includes coverage for all stages and revisions of reconstructive breast surgery performed on nondiseased breast to establish symmetry. Also covered when surgery will restore normal functioning that was impaired by disease, trauma or congenital abnormalities, including delayed surgery for minor children for condition cleft lip or cleft palate. |
| Doctors Health Plan | Covers: Reconstructive surgery to restore normal physiologic functioning due to disease, trauma or congenital anomaly. Includes surgery for minor children for conditions which, for medical reasons, cannot be done at birth. Also covers reconstructive breast surgery resulting from a mastectomy.
Limits: Treatment of congenital defects in children is covered through age 18. Excludes: Surgery for cosmetic purposes or breast reduction surgery. |
| Generations | Covers: Reconstructive surgery needed to correct congenital disease or anomaly, or to correct a functional impairment. Covers post-mastectomy breast surgery. |
| Optimum Choice | Covers: Reconstructive surgery following mastectomy. Includes reconstructive breast surgery performed on non-diseased breast for symmetry with reconstructive surgery on diseased breast. Reconstruction of the nipple/areolar complex following a mastectomy is covered without regard to the lapse of time between the mastectomy and reconstruction. Also covers surgery when needed to correct a congenital defect.
Limits: Requires pre-admission authorization. Reconstruction of nipple/areolar subject to the approval of the treating physician. Cost Sharing: Copayments may apply. Excludes: Cosmetic surgery that is not medically necessary. |
| PARTNERS | Covers: Reconstructive surgery to correct results of disease or injury needed to correct a functional impairment. Covers post-mastectomy breast surgery.
Limits: Requires prior approval. Excludes: Surgeries done primarily to improve appearance. |
| Coventry/Principal Health Care of the Carolinas | Covers: Repair of disfigurement resulting from an injury, reconstruction incidental to surgery and surgery that substantially improves functioning of any malformed body part. Also covers removal of skin lesions that interfere with normal body functions or if malignancy is suspected.
Limits: Reconstructive surgery will be covered only if the cause occurred while the member was enrolled in Coventry/Principal. Excludes: Cosmetic surgery, except for services to correct a congenital defect or an anomaly for newborn, foster or adoptive children. |
| QualChoice | Covers: Reconstructive surgery following mastectomy. Includes reconstructive breast surgery performed on non-diseased breast for symmetry with reconstructive surgery on diseased breast. Also covers reconstructive surgery to correct malformations or anomalies resulting in a functional defect of a covered child. Cosmetic surgery needed to correct physical deformities resulting from trauma, accident, or disease.
Surgery provided as a continuation of the initial medical care, or to restore the function of the injured body part. Excludes: Any procedures, services, equipment or supplies for elective cosmetic surgery intended to improve your appearance or for your psychological benefit. |
| The Wellness Plan of North Carolina, Inc. | Covers: Reconstructive breast surgery and implants following mastectomy, including symmetry for non-diseased breast. Also covered when surgery will repair or correct normal functioning that was impaired by disease, trauma or congenital abnormalities, including cleft lip or cleft palate. |
| United HealthCare | Covers: Services for mastectomy and post mastectomy care. Coverage includes reconstructive breast surgery performed on a nondiseased breast to establish symmetry when reconstructive surgery on a diseased breast is performed. Services covered without regard to the length of time between the mastectomy and the reconstruction.
Also covers reconstructive/cosmetic surgery and related services required to repair a defect caused by an injury, infection or other disease which resulted in a functional defect. Covers surgery to repair a defect caused by a congenital anomaly or disease resulting in a functional impairment. Limits: Reconstructive breast surgery must be approved by the treating physician. prior approval by UHC required for other types of reconstructive surgery. Cost Sharing: Copayments may apply. Excludes: Other types of reconstructive or cosmetic surgery, including but not limited to tattoos and rhinoplasty. |
| WellPath | Covers: Reconstructive breast surgery following mastectomy. Also covers reconstructive surgery if needed to repair damage from an accidental injury, remove a tumor occurring while a member of WellPath, or to correct a birth defect or an anomaly in a bodily function of a dependent child covered by the plan.
Cost Sharing: Copayments may apply. Excludes: Treatment that is primarily intended to improve the member’s physical appearance, whether for emotional, psychological or any other reasons. |