OculoFacial Plastic Surgery & Health Insurance

Within the field of OculoFacial Plastic Surgery, there are different types of procedures that Dr. Lewen routinely performs.

Reconstructive surgery is typically performed on abnormal structures of the body. Such abnormalities can be caused by many different factors such as congenital (birth) defects, developmental abnormalities, trauma, infection, environmental factors, previous surgery, tumors, medical conditions, or disease processes. Reconstructive surgery is generally performed to improve function.

Cosmetic surgery is performed to reshape and rejuvenate normal structures of the body in order to improve the appearance.

Medically necessary surgery is performed when a patient has a condition that is causing significant functional impairment. According to Medicare.gov, “medically necessary” is defined as “health-care services needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” In any of those circumstances, if your condition produces debilitating symptoms or side effects, then it is also considered medically necessary to treat those. Medically necessary surgery must also meet criteria supplied by national coverage determinations and local coverage determinations. These determinations are made by the federal government (at the national level) and by private Medicare contractors (at the local level). For commercial insurance plans, medically necessary surgery may have other specific requirements, limitations, or exclusions that may be specific to the individual health plan.

What’s Covered?

For commercial insurance plans, your insurance policy is an agreement between you and your insurance company. Although Dr. Lewen is able to diagnose and treat many conditions, your insurance plan may have specific restrictions, limitations, or requirements regarding the treatment of certain conditions. Dr. Lewen is not able to force insurance companies to pay for specific surgery, treatments, or services, regardless of your condition. Coverage for services and levels of payment by your insurance company depend on the terms of the contract between you and your insurance company. If you have questions regarding your individual insurance plan, you should contact your insurance company or insurance representative directly.

When you see Dr. Lewen for a reason that is covered by your insurance plan, you may be responsible for a co-insurance, co-payment, and/or deductible amount that is due at the time of your visit when the service is rendered. These amounts are pre-determined by the contract that you have with your insurance company, and Dr. Lewen has no control over these amounts. By contract, you are required to pay all co-insurance, co-payment, and/or deductible amounts that are due at the time service is provided, and Dr. Lewen is required to collect these amounts from you.

For certain surgeries and procedures, an insurance company may often require a prior authorization or approval before the surgery is performed and/or extra documentation after surgery in order to determine how much of the cost of your care will be covered. It is very important to understand that prior authorization and/or pre-approval are not guarantees of payment by your insurance company. Your insurance company will still reserve the right to deny payment for services at their sole discretion. Our office will work with you and your insurance company to help to facilitate coverage in cases where medical necessity exists according to Dr. Lewen. We are also happy to assist you in determining your payment responsibility. Understanding your specific health insurance policy and your responsibility for payment is essential.

In contrast, when you see Dr. Lewen for reasons that are not covered by your insurance plan, the agreement for services and fees due is an agreement between you and Dr. Lewen’s office. In this case, when you have surgery or receive services, you become responsible for payment of the associated fees.

Many forms of reconstructive surgery are covered by health insurance plan, although coverage for specific procedures and levels of coverage will vary greatly among insurance companies. If Dr. Lewen does not have a contract with your insurance company (non-participating), you are responsible for any amount not covered by your plan.

Please Note:  Reconstructive surgery that is performed to fix a complication of a previous Cosmetic Surgery is not covered by most health insurance plans.  You are responsible for these charges and they will not be billed to an insurance carrier.

Cosmetic Surgery is elective, and thus, it is never covered by health insurance plans. Cosmetic surgery is not considered to be a medical necessity. If you are planning to have cosmetic surgery with Dr. Lewen, your surgical fee will depend on the specific surgery that you choose to have, the cost of any required implants or supplies, and the operating time that is involved. At the time of your consultation, Dr. Lewen will review your treatment options, and then Dr. Lewen’s patient coordinator will provide you with an individualized treatment plan with a quotation for the associated costs. The ultimate decision to proceed with surgery is entirely yours.

Dr. Lewen runs his Practice in an honest and ethical manner, appropriate with community acceptable standard of care. Only those claims that are deemed to be for medically necessary services and/or valid reconstructive OculoFacial Plastic Surgery will be submitted to qualified insurance carriers. Any attempt by a patient to misrepresent a desired cosmetic procedure as reconstructive is unethical and fraudulent.