The line separating medically necessary procedures from “just” cosmetic enhancement keeps shifting. And health care insurers might be put in the difficult position (certainly from a public relations standpoint) of drawing that line. The quote marks around “just” above points to the medical community’s growing acknowledgement that procedures once considered cosmetic (and that insurance companies do not cover as a result) morph into medical necessity, argues Jules Lipoff, MD, assistant professor of clinical dermatology at the University of Pennsylvania, in STAT. (This shifting line includes drugs, as well. The February issue of Managed Care includes a story that looks at the far-reaching medical implications of health plans’ stingy coverage for erectile dysfunction medications.)
But Lipoff starts his opinion piece with a no-brainer: the boob job. Most of us think of starlets who want to be ready for their close-up. “But what if it is part of breast reconstruction after breast cancer surgery, or part of gender reassignment surgery for a transgender patient?” Lipoff asks.
Here is the gray area and, all of a sudden, snap judgments about what should and should not be covered can be more difficult to make.
“More and more I find myself arguing with insurance companies to cover treatment of my patients’ skin conditions that are seriously affecting their quality of life,” Lipoff writes. “I fill out countless prior authorization forms and regularly talk peer to peer with medical representatives, advocating for my patients.”
He’s not arguing for carte blanche coverage of everything that falls into the gray area. That’s just not financially feasible. On the other hand, “It’s entirely reasonable to create a set of priorities for how we spend our health care dollars. However, I think insurance companies’ priorities on what they will pay for do not necessarily match what can make real differences in people’s lives.”