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insurance coverage for facial wasting
Aug 22, 2003

What are the individual circumstances by which I might receive insurance reimbursement for plastic surgery needed to ameliorate facial wasting from HIV meds? I have been positive for over 16 years and on meds for 13. It has been showing more and more the last five years after I started taking the triple cocktail. I am still able to work, but since my job does involve my appearance to a fairly large degree (the entertainment industry), I am finding less and less employment opportunities. I am afraid that if I do not do something to ammeliorate the facial wasting I will soon be out of work entirely. Also, the cosmetic surgeon I have met with recommends having an anesthesiologist during the procedure although he says it is not medically necessary. Should I spend the extra money and be put under? With the anesthesiologist he charges 5800 for this. It is 4300 without.

Thank You.

Response from Ms. Franzoi

California Health and Safety Code Section 1367.63 provides that insured health plan contracts entered into, amended, renewed or delivered in California after July 1,1999 must cover "reconstructive surgery." The law specifically does not require a plan to cover cosmetic surgery. "Reconstructive surgery" is defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease to improve function or to create a normal appearance. "Cosmetic surgery" is defined as surgery that is performed to alter or reshape normal structures of the body in order to improve appearance. In March, 2002, the Department of Managed Health Care (DMHC), which regulates plans in California, sent a letter to all plan medical directors regarding coverage for corrective procedures for lipodystrophy. The DHMC noted that patients have been evaluated inconsistently for HIV-wasting and related syndromes with respect to determination of plan coverage for corrective treatment. The DMHC recognized that the Code could be construed to require plan coverage for cosmetic treatment for lipodystrophy and related syndromes, in light of clinical issues and findings. However, this would not apply to self-insured health plans because they are not subject to state insurance laws. The laws in other states would govern what insured plans in those states cover.

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