Understanding Claim Denials in Plastic Surgery

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Understanding Claim Denials in Plastic Surgery

• Claim denials in plastic surgery can have several
  negative consequences for both the patient and
  the plastic surgeon. Apart from financial losses,
  claim denials in plastic surgery could lead to
  delayed treatments, increased administrative
  burden, negative impact on patient satisfaction,
  and overall damage to the plastic surgeons
  reputation. It is important for plastic surgeons
  to work closely with insurance companies to
  ensure that claims are submitted correctly and
  that denials are minimized.
• Claim Denials in Plastic Surgery
• Apart from common medical billing claim denials
  like inadequate documentation, provider not in
  network, and inactive coverage claim denials
  specific to plastic surgery include
• 1. Cosmetic Procedure
• If the procedure is deemed cosmetic rather than
  medically necessary, the insurance company may
  deny the claim. For example, breast augmentation
  surgery for cosmetic reasons would not be
  covered. Most insurance companies do not cover
  elective cosmetic procedures such as rhinoplasty,
  breast augmentation, or liposuction. Procedures
  that are considered medically necessary, and may
  be covered by insurance, include breast
  reduction, reconstruction after breast cancer
  surgery, and reconstructive surgery following an
  injury.

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Understanding Claim Denials in Plastic Surgery
The reasons for cosmetic procedure claim denial
can vary depending on the specific insurance
policy and the procedure in question. As
mentioned earlier, insurance companies will only
cover plastic surgery procedures if they are
deemed to be medically necessary, meaning that
they are required to treat a specific medical
condition or injury. Cosmetic procedures, on the
other hand, are typically performed to enhance a
patients appearance rather than to treat a
medical condition. Insurance companies may view
these procedures as elective or optional, and
therefore not covered by the policy. 2.
Pre-Existing Condition Image Source
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Understanding Claim Denials in Plastic Surgery
A pre-existing condition is a health condition
that existed before an individual obtained health
insurance coverage. In the context of plastic
surgery, a pre-existing condition may be a
medical condition that existed before the surgery
and could impact the outcome of the procedure or
pose a risk to the patient during or after the
surgery. Insurance companies may deny claims
related to pre-existing conditions if the
condition is deemed to be related to the plastic
surgery procedure. For example, if a patient has
a pre-existing medical condition such as high
blood pressure, diabetes, or a heart condition,
the insurance company may deny the claim if they
believe that the surgery could worsen the
pre-existing condition or pose a risk to the
patients health. Insurance companies may also
require patients to undergo a pre-surgery
evaluation or provide medical documentation to
determine whether a pre-existing condition exists
and whether the surgery is medically
necessary. 3. Experimental or Investigational
Procedure Experimental or investigational
procedure claim denials in plastic surgery
typically occur when an insurance company
determines that a particular procedure or
treatment is not medically necessary or not
supported by clinical evidence. In plastic
surgery, experimental or investigational
procedures may include treatments that are not
yet widely accepted in the medical community, are
still undergoing clinical trials, or have not been
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Understanding Claim Denials in Plastic Surgery
proven to be safe and effective for a particular
condition. Insurance companies have established
medical policies that determine which procedures
they will cover and which ones they consider
experimental or investigational. If a procedure
is considered experimental or investigational,
the insurance company may deny coverage, leaving
the patient responsible for the entire cost of
the procedure. In some cases, patients and their
plastic surgeons may appeal an insurance denial
of coverage for an experimental or
investigational procedure. The appeal may include
additional documentation or evidence to support
the medical necessity of the procedure. 4. Lack
of Medical Necessity A lack of medical necessity
claims denial in plastic surgery typically occurs
when an insurance company denies coverage for a
plastic surgery procedure because they deem it to
be cosmetic rather than medically necessary.
Medical necessity refers to the need for a
particular medical treatment or procedure to
address a specific health condition. In the case
of plastic surgery, a procedure may be deemed
medically necessary if it is required to improve
or restore bodily function, treat a deformity
resulting from a congenital condition, injury, or
disease, or alleviate physical pain or discomfort.
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Understanding Claim Denials in Plastic Surgery
However, if the plastic surgery procedure is
primarily for cosmetic purposes, meaning it is
not essential to treat a medical condition or
symptom, then the insurance company may classify
it as an elective or optional procedure and deny
coverage. Insurance companies have specific
guidelines and criteria for determining medical
necessity and what procedures are covered. For
example, some insurance companies may cover
certain reconstructive surgeries following a
mastectomy or surgery to correct a deviated
septum that causes breathing difficulties.
However, they may deny coverage for procedures
such as breast augmentation, liposuction, or
rhinoplasty if they are deemed purely
cosmetic. 5. Non-Compliance with Post-Operative
Instructions Image Source
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Understanding Claim Denials in Plastic Surgery
Non-compliance with post-operative instructions
is a common reason for claim denial in plastic
surgery. When a patient undergoes a plastic
surgery procedure, they are given specific
instructions to follow after the surgery to
ensure a safe and successful recovery. If a
patient does not follow these instructions and
experiences complications as a result, their
insurance claim for additional treatment may be
denied. For example, if a patient is instructed
to avoid strenuous exercise for several weeks
after their surgery but returns to their usual
workout routine too soon and suffers a
complication such as a wound opening up or an
implant shifting, the insurance company may argue
that the patients non-compliance with
instructions led to the complication and deny
coverage for any additional treatment needed to
address the issue. It is important for patients
to follow their post-operative instructions
closely to ensure a safe and successful recovery
and to avoid potential claim denials by their
insurance company. To summarize, It is
important for providers to fully understand
patients insurance policy and coverage before
undergoing any plastic surgery procedure. To
avoid claim denials in plastic surgery, always
stay in touch with insurance companies to ensure
that patients receive the appropriate coverage
for their surgery and any related pre-existing
conditions.
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Understanding Claim Denials in Plastic Surgery
Its important to note that insurance companies
coverage policies and criteria vary, and what one
insurance company may consider medically
necessary, another may not. Medical Billers and
Coders (MBC) is a leading medical billing company
that offers medical billing and coding services
to healthcare providers of various medical
specialties. MBC has been in the medical billing
industry for over 20 years and has worked with
healthcare providers of different specialties and
sizes. We have a team of certified medical
coders and billers who provide a range of
services, including benefits verification,
medical coding, charge entry, claims submission,
payment posting, denial management, accounts
receivable, and provider credentialing. To know
more about our plastic surgery billing and coding
services, email us at info_at_medicalbillersandcoder
s.com or call us at 888-357-3226.