Most cosmetic procedures don’t qualify for health insurance. But here’s the nuance: when a procedure treats a documented functional problem, not just appearance, carriers may cover some or all of it.
In this guide, I’ll show you when insurance covers cosmetic surgery, what insurers look for under medical necessity, which ICD-10/CPT codes often appear in functional cases, and how to write a letter of medical necessity that actually helps.
Insurance sometimes pays when your surgeon proves the procedure treats pain, obstruction, infection, or impaired function and you’ve tried appropriate non-surgical care first. Documentation wins the day.
“Cosmetic” vs “Medically Necessary” (What Insurers Actually Mean)
Insurers approve procedures that treat disease, correct functional impairment, or relieve documented symptoms after appropriate conservative care.
They deny procedures performed only to change appearance.
Think in this order:
- Diagnosis: What condition do you have? (e.g., nasal obstruction, symptomatic macromastia, visual field loss from eyelid skin, rashes under a large pannus)
- Symptoms + Impact: How does it affect daily life? (pain, infections, limited vision, breathing problems, activity limits)
- Conservative Treatment: What did you try and for how long? (physical therapy, weight loss, specialty bras, medications, topical antifungals, nasal sprays, allergy treatment)
- Objective Findings: What proves the problem? (photos, visual field tests, BMI and weight-stability logs, PT notes, allergy or sleep studies, dermatologist notes, primary-care visits)
- Procedure Plan: Why this procedure solves the problem, with the expected functional benefit.
If your chart checks those boxes, your chances go way up.
Common Procedures Sometimes Covered
Important: Policies vary by carrier and state. The examples below are illustrative and not a guarantee of coverage.
| Procedure (Often Cosmetic) | When Insurers Sometimes Cover | Typical “Medical” Angle (Examples) | Example Codes* |
| Breast Reduction | Yes, with strict criteria | Chronic neck/back/shoulder pain, intertrigo, shoulder grooving; failed PT, specialty bras, meds; Schnur scale weight removal | CPT 19318; Dx: N62 (hypertrophy), L30.4 (intertrigo) |
| Functional Rhinoplasty/Septoplasty | Sometimes | Nasal obstruction, valve collapse, trauma deformity; failed sprays, allergy care, CPAP intolerance | CPT 30520 (septoplasty), 30465 (valve repair); Dx: J34.2, J34.3 |
| Upper Eyelid Blepharoplasty | Sometimes | Documented visual field loss from dermatochalasis/ptosis; formal visual field testing | CPT 15823; Dx: H02.831–H02.834 |
| Panniculectomy (not full tummy tuck) | Sometimes | Recurrent rashes/infections under a large pannus; failed medical therapy; weight stability after massive loss | CPT 15830; Dx: L30.4, E66. (obesity), Z98.84 (bariatric status) |
| Otoplasty | Rare/variable | Severe deformity or recurrent infections/trauma issues; often excluded when purely cosmetic | CPT 69300; Dx varies |
| Botox for Chronic Migraine (not cosmetic lines) | Medical (not cosmetic) | Chronic migraine meeting criteria; prior med failures; administered for migraine, not wrinkles | CPT 64615, J0585; Dx: G43. |
*Codes shown for education only; your surgeon/billing team will determine final coding based on your chart and payer rules.
We believe that achieving your beauty goals should be accessible to everyone. That’s why we offer flexible and affordable cosmetics surgery financing options for you.
What Insurance Looks For (The Documentation That Moves Needles)
Create a clean paper trail. Your pre-authorization (and appeal, if needed) gets much easier with:
- Detailed symptom timeline: how long, how often, and how severe.
- Functional limitations: work, exercise, sleep, driving, reading, skin care, hygiene.
- Conservative therapy logs: dates and outcomes of PT, specialty bras, weight loss, nasal sprays, antibiotics/antifungals, allergy meds, dermatology care.
- Objective tests: visual fields for blepharoplasty; nasal endoscopy/allergy or sleep data for rhinoplasty; rash cultures/derm notes for pannus; weight-stability records for massive weight loss.
- High-quality photos: standard views in good lighting.
- Co-managing clinicians’ notes: PCP/ENT/derm/physical therapy supporting the diagnosis and failed conservative care.
- Clear surgeon plan: procedure, expected functional benefit, and code set.
ICD-10 & CPT (So You Can Follow Along)
- ICD-10 = the diagnosis (what’s wrong). Example: N62 (macromastia), J34.2 (deviated septum).
- CPT = the procedure (what’s being done). Example: 19318 (reduction mammaplasty), 30520 (septoplasty).
- Carriers approve or deny based on the ICD + CPT combo and your medical necessity story.
- Your surgeon’s team assigns codes; you don’t need to pick them. But understanding the basics helps you ask sharper questions and submit better supporting documents.
How to Write a Letter of Medical Necessity
(Template You Can Use)
A Letter of Medical Necessity (LMN) isn’t just a note, it’s your case summary.
Ask your surgeon’s office to submit their clinical letter and consider attaching your own patient letter that echoes the facts in plain language.
Patient LMN Template (copy/paste and personalize):
Subject: Letter of Medical Necessity – [Your Name, DOB, Member ID]
To: [Insurance Carrier Name], Pre-Authorization Department
I’m requesting coverage for [procedure] by [surgeon, practice] to treat [diagnosis].
Symptoms & Impact: For the past [X months/years], I’ve had [list symptoms] that limit [work, sleep, exercise, daily care].
Conservative Care Tried: I completed [PT sessions, specialty bras, medications, topical treatments, weight loss of X lbs, nasal sprays, allergy care, etc.] from [dates] with [limited/no] relief.
Objective Findings: [Attach/test results/photos/visual fields/derm notes/ENT notes] confirm [diagnosis].
Requested Procedure & Expected Benefit: [Procedure] will address [functional problem] and is expected to improve [breathing, pain, infections, vision, mobility].
Thank you for reviewing my request. Please contact me at [phone/email] if you need additional documentation.
Sincerely,
[Your Name]
Pro tip: Match dates and facts to your surgeon’s records. Consistency builds credibility.
How to Talk to Your Insurance Carrier (Without Getting Stuck)
- Call the number on your card and ask for pre-authorization requirements for your specific policy.
- Ask for the medical policy bulletin name/number (e.g., “breast reduction medical policy”). Save it as a PDF.
- Confirm in-network vs out-of-network benefits and whether your surgeon’s facility is accredited and in network.
- Get a reference number for every call. Write it on your notes.
- Ask what conservative therapies and how long they require before surgery.
- Ask whether they need photos, test results, or specialist notes and in what format.
- If denied, request the exact reason and a copy of the policy they used, then work with your surgeon to appeal with the missing pieces.
Timing & Expectations
- Pre-auth takes time. Start the process 6–12 weeks before your target surgery date.
- You may get a partial approval. Insurers might approve the functional portion (e.g., septoplasty) but not the purely cosmetic piece (e.g., a dorsal hump rasp).
- Appeals work when you add the missing clinical pieces. Ask your surgeon’s office to lead the appeal with you.
FAQs
Does insurance cover cosmetic surgery?
Sometimes, only when the procedure treats a documented medical problem and conservative care didn’t work.
What insurance covers cosmetic surgery?
No carrier “covers cosmetic surgery” by default. Carriers may cover medically necessary procedures under specific policies and criteria.
Do I need a letter of medical necessity?
Yes. A strong LMN, paired with your surgeon’s clinical documentation, photos, and tests, can flip a denial into an approval.
Will insurance pay for a surgery that’s part medical, part cosmetic?
Often they’ll cover the functional components and leave the cosmetic parts as self-pay. Your surgeon can separate fees and codes so you understand both portions.
Next Steps (Your 10-Minute Action Plan)
- Book a consultation with a board-certified surgeon to confirm diagnosis and candidacy.
- Gather conservative care proof (PT logs, meds, specialist notes).
- Get photos and any required tests (visual fields, ENT evaluation, dermatology notes).
- Ask the office to submit a pre-auth with a complete packet and your patient LMN.
- If denied, request the policy bulletin and appeal with the missing evidence.
Bottom Line
Insurance can cover procedures people often call “cosmetic” when your records prove a medical problem and failed non-surgical care.
Your best strategy pairs a knowledgeable, board-certified surgeon with careful documentation, appropriate ICD/CPT coding, and a crisp letter of medical necessity.
Build the file right the first time, and you give your claim the best chance to land in the approved pile.
With over 25 years of unparalleled expertise, BGMG Cosmetics stands as Los Angeles’ premier full-service cosmetic surgery center. Since 1999, we have proudly transformed the lives of over 50,000 satisfied patients, consistently delivering exceptional and life-changing results.
