Services that are reconstructive, corrective, or cosmetic
Most HMSA plans cover reconstructive or corrective surgery and services when they meet HMSA’s criteria. Please review HMSA’s medical policy on Cosmetic and Reconstructive Surgery and Services for more information.
Reconstructive or corrective services are a benefit of your plan when they are required to restore, reconstruct, or correct a bodily function that was lost or impaired or damaged due to an illness or injury. HMSA plans do not cover purely cosmetic services, that is, surgery or supplies that are primarily done to improve your natural appearance (for example, hair transplants, electrolysis, ear or body piercing), but do not restore or improve a physical function. For most plans, complications from non-covered cosmetic surgery are not covered.
Most HMSA plans cover breast reconstruction when a mastectomy was performed as well as surgery for reconstruction of the other breast to produce a symmetrical appearance (including prostheses). Treatment of complications of the mastectomy and reconstruction, including lymphedema (post-treatment swelling that occurs), is also covered.
Services to correct developmental abnormalities present from birth that prevent you from having normal, essential bodily function would also be covered. For example, cleft lip/cleft palate surgery in a newborn that has difficulty breastfeeding may be performed so that your child may feed without difficulty.
Certain reconstructive surgery and services may be covered if your condition meets HMSA’s payment and medical policy criteria. These may be available only if precertification is obtained. For more information, please review Prior approval for medical services (precertification) for information about the precertification process. Also, review the following medical policies if they apply to the service you are requesting: