When does health insurance cover the costs of plastic surgery?


Cosmetic surgery in the classic sense represents a medically unnecessary, but by patient request initialized intervention represents. For this reason, the statutory health insurance does not normally cover the costs of such operations. Accompanying costs, such as a stay in a private clinic with room and board, must also be paid by the patient.

Physical or mental impairments must be proven

However, there are also reasons that can make the use of plastic or cosmetic surgery medically provable. These include, for example, a demonstrable, mental impairment by certain body characteristics, such as an excessively large or small breast. Congenital malformations, e.g. of the nose or ears, can also justify medical intervention.

After major surgery, injury and Diseases, for example, after breast surgery due to a tumor, the health insurance company usually covers the entire cost of breast reconstruction or reconstruction of the breast.

If a patient can prove that he or she is likely to be able to maintain the weight at a certain level permanently after a major weight reduction, the health insurance company will pay for plastic-aesthetic operations, such as an abdominoplasty or the removal of excess skin flaps.

An application for cost coverage alone is not sufficient

If a procedure is planned in which a medical or psychological indication is present, the attending physician shall draw up a report with which the Request for reimbursement can be made by the statutory or private health insurance. In addition, a assessment by the medical service of the relevant health insurance company. must be completed. Here, a decision is made on a case-by-case basis, taking into account the guidelines of the respective health insurance company, as to whether costs can be covered.

In the case of a psychological justification for the intervention, the health insurance company will provide a psychological report request from which a clear need for the operation due to a strong psychological impairment emerges. This may be the case, for example, with extremely asymmetrical breasts or the male Gynecomastia, a benign enlargement of the male mammary gland tissue (provided it is due to hormonal influence and not to obesity). Breast enlargements due to too small breasts are usually not considered a sufficient reason and must be paid for by the patients themselves.

What to do if the health insurance does not pay for the procedure?

If the health insurance company refuses to cover the cost of the procedure due to insufficient medical justification, the patient’s only option is to Self-payer option. Many doctors and clinics, including Dr. Martha Bernard, offer the Possibility of financing is available. More detailed information is available to interested patients directly in a personal consultation with Dr. Bernard.

Functional limitations always require a medical indication

If there is a functional limitation is present, which affects the patient’s life, the health insurance company will almost always cover the cost of correction. Such indications can be:

  • protruding ears: Up to the age of school entry, protruding ears can be corrected without any problems at the expense of the health insurance, after that only in individual cases.
  • Dysfunctions of the nasal cavity: Functionally limiting changes of the nasal cavity that interfere with breathing or cause recurrent infections may also be operated on at the expense of health insurance.
  • Eyelid correction: If there is a significant restriction of the visual field, such as a drooping upper eyelid or severe wrinkling, correction may be medically justified.
  • Scars and skin changes: Improving the appearance of scars, especially those with functional limitations or pain, may be covered by health insurance. The removal of malignant, but also benign skin changes such as moles, is usually covered as well.
  • Abdominoplasty and liposuction: If the removal of skin flaps or fat aprons is necessary for medical reasons, such as recurrent eczema, skin irritation and fungal diseases, the procedure will be paid for. However, a condition is often proof that, for example after a major weight loss, the new weight can be maintained consistently over time. Liposuction is medically indicated only if it is a Lipodystrophy or around Lipid Edema This is pathological fat accumulation or severe lymphatic drainage congestion due to abnormal adipose tissue overgrowth.
  • Breast Reductions: In the case of excessively large breasts, the health insurance company will usually first approve weight reduction measures and physiotherapy. If, despite physiotherapeutic measures, there is severe discomfort in the shoulder, neck and back area, or if there is recurrent eczema and inflammation in the area of the underbust fold, a surgical reduction may be possible if the costs are covered. In the case of a Gynecomastiaa hormonally induced, benign enlargement of the mammary gland tissue, which mainly occurs in men, can also be expected to be covered after clarification of the causes.