Understanding Health Insurance Coverage for Plastic Surgery (2023)

In the era of burgeoning social media, the dissatisfaction with personal appearance is on the rise. The aesthetic standards set by images on social platforms have, consciously or not, created a style to be followed both in attire and behavior, as well as in aesthetics. As a consequence, Brazil has emerged as the global leader in plastic surgeries among young individuals, according to the International Society of Aesthetic Plastic Surgery (ISAPS). Statistics confirm that approximately 2.5 million aesthetic procedures are performed annually in the country.

The quest for plastic surgery is not solely tied to aesthetics; emotional distress exacerbated by imposed social standards can justify corrective plastic surgery. For instance, deformities in the nose hindering breathing or impacting mental health, excessively large or small breasts causing embarrassment or pain – these factors contribute to the demand for plastic surgery.

When Does Health Insurance Cover Plastic Surgery?

According to the National Supplementary Health Agency (ANS), health insurance is obliged to cover plastic surgeries, but with some caveats. There is a list of procedures that the insurance must cover in the Procedures and Events Rol, known as reparative interventions.

It is crucial to initially opt for an outpatient hospital plan. The next step is to determine if your need for plastic surgery is included in the ANS list. If not, checking the contract with the health insurance provider for the inclusion of other types of surgeries is essential. Additionally, there must be medical relevance – an indication by a professional of the necessity for reparative surgery, following Utilization Guidelines.

Otherwise, while the health insurance may support with preoperative consultations and exams, the expenses related to the procedure are the patient's responsibility.

Esthetic vs. Reparative Plastic Surgeries

In general, health insurance plans do not cover surgical plastic procedures performed solely for aesthetic purposes. The distinction lies in the objective. Reparative surgery aims to restore injuries, defects, or deformities of the patient, improving not only aesthetics but also the overall quality of life. On the other hand, aesthetic surgeries are performed solely for appearance enhancement and are not included in the Procedures and Events Rol.

ANS Guidelines on Plastic Surgery

Regulated by the ANS, certain surgical procedures must be covered by insurance if they are aimed at correction, repair, or reconstruction. Some of the recommended plastic surgeries that health insurance should cover include:

  • Breast reconstruction: for patients with injuries due to trauma, cancer diagnosis, or mastectomy.
  • Breast reduction: when necessary for health reasons, such as if the size of the breasts is detrimental to health and quality of life.
  • Burn scars, scars, and keloids: surgeries to repair these complications should be covered by the insurance due to potential emotional problems for the patient.
  • Blepharoplasty or eyelid skin reduction surgery: covered if the excess skin affects the patient's vision.
  • Excess skin removal: necessary for patients with excess skin due to weight loss, especially after bariatric surgery.
  • Prostheses, appendages, and orthoses: coverage is required if deemed necessary.

How to Request Plastic Surgery Through Insurance

The process involves familiar steps with a medical insurance plan: scheduling a consultation, expressing interest, and undergoing assessments. However, it's essential to note that these procedures often have longer waiting periods compared to routine consultations and exams. Therefore, checking with the insurance provider beforehand is crucial to determine the eligibility for plastic surgery.

Reparative surgeries require medical communication and, through a medical report, a necessity certificate for the procedure. Even with these documents, the insurance company may request an evaluation by another professional before approving the surgery.

Choosing the Right Health Insurance – Choose Sami

At Sami, our mission is to provide quality healthcare at a fair price. Each Sami member has access to their own Health Team, including a personal doctor and a nursing team that genuinely understands you. Our network of clinical partners, the Sami Clinical Partners, includes high-quality hospitals, maternity wards, clinics, and laboratories such as Beneficência Portuguesa, Hospital Oswaldo Cruz (Vergueiro unit), Santa Joana and Santa Izildinha maternity wards, Labi laboratories, among others.

Finally, we recognize that health is more than just a health insurance card. That's why we've created our Healthy Habits Network, with the Gympass app for gyms and exercises, plus exclusive additional features like guided meditation, yoga, mindfulness exercises, and even digital therapy – all included in the plan at no extra cost.

Interested? Click the button below for a quote. Our plans are available for individual entrepreneurs (MEI) and legal entities (PJ) from 1 person upwards in the cities of São Paulo, Guarulhos, Osasco, Taboão da Serra, and ABC, with prices starting at R$ 172 per month per person.

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