Insurance

Navigating Your Insurance Coverage: Our Commitment to Patient Advocacy

Understanding insurance can be the most challenging part of planning for surgery. At Specialized Plastic Surgery, we believe your focus should be entirely on your health and achieving your desired results—not on fighting with insurance companies. That’s why we have built a dedicated team of insurance specialists to manage the complex administrative process for you.

Our Insurance Policy: Out-of-Network Excellence

We operate as an Out-of-Network provider with most major insurance carriers. This allows our board-certified surgeon to maintain complete autonomy over your care, ensuring you receive the highest standard of specialized treatment without the limitations often imposed by restrictive networks.

We do the hard work for you.

While we are out-of-network, our specialized team excels at maximizing your benefits. We handle the entire pre-authorization and claims process, including:

Submission: Preparing and submitting all required documentation, including clinical photos, letters of medical necessity, and operative reports.
Monitoring: Diligently tracking your pre-authorization status and following up with your carrier until a decision is reached.
Appeals: Advocating on your behalf if an initial request is denied.

This process ensures that you can focus on your preparation and recovery while we manage the complexities of securing your coverage.

Insurance Coverage for Reconstructive Procedures

For patients undergoing breast reconstruction, federal law ensures coverage for your procedure.

The Women’s Health and Cancer Rights Act of 1998 (WHCRA)

At Specialized Plastic Surgery, we are particularly passionate about offering breast reconstruction services to our patients,and we want to ensure that all patients understand their rights regarding coverage for this essential procedure. Under the Women’s Health and Cancer Rights Act of 1998 (WHCRA), health insurance providers are required to cover breast reconstruction surgery following a mastectomy. This federal law mandates that insurance plans cover the cost of breast reconstruction, as well as surgery to achieve symmetry between the breasts, and any prosthetics needed as part of the reconstruction process.

This legislation is a vital step in ensuring that women who have undergone mastectomy due to breast cancer have access to the restorative procedures they need to feel whole again. Our team is fully aware of WHCRA and can help guide you through the process of working with your insurance providers to receive coverage. We believe that no woman should have to compromise on her care or be burdened with financial stress while pursuing breast reconstruction. If you have any questions about WHCRA or need help understanding your rights under this act, our team is here to support you.

For more detailed information on the WHCRA and how it impacts your rights to breast reconstruction, we recommend visiting breastreconstruction.org. This valuable resource provides information on reconstruction options, insurance guidance, and support resources for patients considering or undergoing breast reconstruction.

For patients undergoing breast reconstruction, federal law ensures coverage for your proceduThe WHCRA is a critical federal law that mandates coverage for breast reconstruction for patients who have had a mastectomy in connection with breast cancer. If your group health plan covers mastectomies, it must also cover:re.

All stages of reconstruction of the breast on which the mastectomy was performed.
Surgery and reconstruction of the opposite breast to achieve symmetry.
Prostheses and treatment for complications (e.g., lymphedema) that arise from the mastectomy.

Our team has an in-depth understanding of the WHCRA and uses it to ensure you receive the comprehensive, high-quality reconstructive care you are entitled to, regardless of our out-of-network status.

Insurance

Exploring Coverage for Medically Necessary and Aesthetic Procedures

While aesthetic procedures are generally not covered by insurance, certain operations that address functional or health issues can be covered, either fully or in part.

Breast Reduction Coverage

Breast reduction surgery (reduction mammoplasty) is one of the most common procedures covered by insurance when it is performed for medical necessity. Coverage is typically approved when the procedure alleviates documented chronic symptoms caused by the weight of large breasts, including:

Chronic, debilitating pain in the neck, back, or shoulders.
Recurrent skin irritation or rashes (intertrigo) beneath the breast crease.
Deep grooves or indentations in the shoulders from bra straps.

Our team works with your carrier to demonstrate that non-surgical treatments have failed and that the surgery meets the specific tissue removal requirements of your policy.

Portions of Body Contouring Procedures

We specialize in securing coverage for the medically necessary components of complex body contouring surgeries, especially those following massive weight loss or pregnancy:

Abdominoplasty (Tummy Tuck): While the removal of excess skin is cosmetic, the repair of significant diastasis recti (separation of the abdominal muscles) that causes functional issues (like back pain or core weakness) may be eligible for partial coverage.
Body Lift Procedures After Bariatric Surgery: The removal of heavy, hanging skin (a panniculectomy) after massive weight loss can be covered if the excess skin causes recurrent infections, hygiene issues, or functional impairment.

Our team will meticulously review your medical records, including weight loss history and clinical symptoms, to present the strongest possible case for coverage.

Insurance

Your Next Step

Don’t let the complexity of insurance be a barrier to seeking the care you need. During your complimentary insurance verification consultation, our dedicated specialists will go over all of your options, review your specific policy, and map out the entire pre-authorization process for you.

Contact us today to let our team start the heavy lifting

CALL US NOW: (914) 874 – 0900

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