Is it worth to ask my insurance company for a "cosmetic" fix to my ear?
December 1, 2020 10:10 AM   Subscribe

This is a hard question to ask, but I'm thinking about asking my (USA-based) health insurance company for a medically necessary surgery/fix to my right ear, which is in the form of microtia.

For 30+ years now, I have accepted my half-grown right ear (image) as part of who I am, but over the last few years, I've been ready to move forward with some kind of surgery or attachment to "fix" this part of myself. This has grown more urgent with COVID. Here's why:

a) I wear glasses. It's a pain to adjust to the half-grown ear for the legs of the eyeglasses frame. It's constantly slipping. I don't want to wear a strap or something like that around my head, it's annoying and looks weird.

b) With masks, it's impossible to put on masks with ear straps, unless I break the strap and tie it around my head, but even then that's inconvenient and would just snap away, especially with thin straps. I get around this by wearing my own mask with tie-around straps, but it's a pain and some places are getting more and more insistent that people wear THEIR masks (which is almost always ear straps).

c) This is more personal, but it makes me stand out and look different. I'm tired of that. It's okay to be different! But for me, personally, I'm just tired of it. I'm tired of kids staring openly at my ear, and some people giving me second looks.

So, I want to try and declare that this is medically necessary and not "cosmetic", given glasses, COVID masks, etc., and do some kind of single case agreement or something like that. My current health provider is United HealthCare, through my employer; I have a $1500 deductible (I think), and it's a pretty basic plan, but it's comprehensive (again, I think - not too familiar with how insurance works).

I can't afford a surgery or whatnot on my part-time pay, so I'm wondering what options I have at my disposal, or how I can negotiate this with my insurance company, and persuade them this is medically necessary? Do you have any suggestions, or am I missing something? That would be much appreciated, thanks.
posted by dubious_dude to Health & Fitness (10 answers total)
my advice would be to talk with your surgeon's office about their willingness to help you negotiate it. They'll know the best words to use, etc.

(anecdata: our derm's office went to bat for my family regarding the cost of a cosmetic-ish procedure that they said was very rarely covered but "worth a try." They got it covered. It's in their interest to get it covered if the alternative is you not doing it. We also have employer-provided UHC.)
posted by fingersandtoes at 10:22 AM on December 1, 2020 [5 favorites]

As a starting point, you would need a doctor to determine that it is medically necessary and then they would file the paperwork to get approval and then argue with the insurance company when it is denied. You can involved, but it won't go anywhere if you don't have an MD willing to say in writing that it medically necessary.
posted by metahawk at 10:23 AM on December 1, 2020 [7 favorites]

A quick glance through UHC's guidelines show they generally consider microtia surgery reconstructive (rather than cosmetic), even with no documented medical problems associated with it. (Though of course you'll want to check your specific plan, and some states have different rules about what cosmetic procedures MUST be covered as reconstructive.) So you'll want to proceed in whatever typical way your plan has you proceed, whether that's having your primary care doctor refer you to an in-network surgeon, having you self-refer, or having you start with the insurance company itself. Your surgeon's office (once you get to that point) will be able to walk you through the insurance coverage process and help you get necessary approvals.

But I think it really shouldn't be a problem to get UHC to approve it, especially since you can document specific problems with glasses and masks -- it's impairing your functioning in everyday life. (But even "making me feel self-conscious" will often get an insurance company to approve a cosmetic surgery on an atypical-looking physical feature as reconstructive.)

You can always contact UHC's customer outreach people (usually phone numbers on the back of your card, although they're increasingly providing web-based service too) and just ask them to walk you through your policy's coverage for microtia surgery and what you'd need to do. I did this a LOT when my kids were little and I was learning through experience what was and wasn't covered for pediatric care -- they're typically very helpful when you just have questions about your policy or about accessing care. (They're less helpful when you want to argue with them about coverage, but that's why you have the doctor's office's insurance people do the arguing, if necessary.)
posted by Eyebrows McGee at 10:34 AM on December 1, 2020 [7 favorites]

I think you would have mentioned this if it was at all applicable, but if it affected your hearing then that might be a relevant factor. If you have not had your hearing tested in the last several years, it may be worth doing so. In the run up to my ear surgery (mastoidectomy), I would have told you my hearing in that ear was fine until I saw the results of the test which actually showed a significant difference.

In another not-very-related but maybe insightful to the way insurers think or a strategy to approach this .... As an infant my son was evaluated for something called positional plagiocephaly which is often simply a cosmetic issue where the back of a baby's head is flatter than thought desirable, however it can sometimes be severe enough to have neurological issues for the child or result in eye/ear asymmetry. Custom orthotics (baby helmets) can treat this, and insurance sometimes considers it elective/cosmetic and sometimes considers it medically necessary. We met with a pediatric plastic surgeon, who concluded that there was no neurological impact or asymmetry for my son and that we could do the helmet stuff if we wanted but we didn't need to. I bring this up because even though he had made that conclusion, he was willing to write a letter of medical necessity to our insurance company to get the orthotics covered. Like fingersandtoes says above, helping make a case for medical necessity is something that doctors do and would not be out of line for you to raise the issue, discuss and request such a letter, and that's generally how it's done - through the doctor to the insurer (similar to pre-approvals etc.).
posted by MustangMamaVE at 10:40 AM on December 1, 2020

Some states provide consumer healthcare advocacy that assists people with questions like these. Search terms like "healthcare" "advocate" "ombuds" "ombudsman" "ombudsperson" + your state.

If you live in NY or CT send me some memail and I can directly connect you with the relevant people.
posted by gauche at 10:44 AM on December 1, 2020

Wow, very helpful answers so far! A quick followup:

a) I'm Deaf (profoundly, both ears) and have been since birth. We aren't sure if this had something to do with the half-grown ear or not, but as there's hearing people with microtia, I'd say maybe not? But yes, Deaf 100%.

b) Eyebrows McGee's answer was definitely very reassuring! I'll call UHC and see what they have to say. Follow-on questions: how much should I expect to pay out of pocket for the surgery; would it be complicated and constitute taking out any of my body parts; and would COVID limit my options to get a surgery (kind of a catch-22 here)? I plan to ask them those questions but wanted to get a pulse here as well.

I'm in the DC area, but will try the ombuds route.

c) Are there major differences between cosmetic and reconstructive?
posted by dubious_dude at 10:47 AM on December 1, 2020

An anecdote: When I was dealing with (different cosmetic-related body issue, also on my head) the big game changer for me was when my doctor pointedly said, "Well does it cause you pain?" and when I started to say no (truthfully) she interrupted me and said, "It looks like it's really causing you a lot of pain." By which I came to understand that if I said, "It's causing me pain," she would be able to write me the kind of referral that would make it magically covered by insurance. I did, she did, and it was.
posted by BlahLaLa at 11:30 AM on December 1, 2020 [3 favorites]

"c) Are there major differences between cosmetic and reconstructive?"

For insurance company purposes, cosmetic surgery takes a "normal" body part and improves it. Reconstructive repairs something injured or removed, or makes a congenital abnormality or physical difference conform to more typical development (such as in your case). (Sorry, it's very hard to talk about "reconstructive" surgery in an insurance company context without using stigmatizing language, since that's how they label.) In reality it's all a continuum from "make my giant boobs more giant so I get more acting jobs" to "reconstruct new breasts after my mastectomy" to "reduce my breasts so I have less back pain," and many things are a combination of improving function (being able to wear glasses), reducing visible physical differences that may make someone self-conscious (your third reason), and someone who simply wants to look different.
posted by Eyebrows McGee at 11:30 AM on December 1, 2020 [2 favorites]

What Eyebrows said, basically. There is a continuum between "cosmetic" and "reconstructive" in that reconstructive surgery is covered by insurance and cosmetic is not, even when it's the exact same procedure. The subjective criteria doesn't always entirely add up to logic, but is rooted in a judgement about whether you're changing your appearance for funsies vs solving a problem. (A poignant example of this is that gender-affirming surgeries are now often covered by insurance in many states, which is a shock and a half several of my trans friends who spent years expecting to pay completely out of pocket.)

Anyhoo, obviously a lot of parents of children with microtia decide to pursue reconstructive surgery; the fact that you are an adult might get a quick second glance from the insurer, but at the end of the day they're going to consider this a covered procedure for a congenital deformity (sorry, language, ugh.) The fact that you need eyeglasses makes it an even easier call. You might have to jump through some referral hoops, but otherwise, you should be able to pursue this straightforwardly without apology.
posted by desuetude at 9:59 PM on December 1, 2020

Thanks for the help!

An update: called UHC, explained my situation, and got a few possible referrals. I was told they'd cover 80% of the surgery, but with my deductible and the maximum out-of-pocket charges, I'd pay a total of $5000 as the maximum.

Now, just have to find a local surgeon in-network, hopefully for less than $5000 I'd spend out of pocket! I wish I would have known this a long time ago, I always thought that it was cosmetic and I'd be out of luck in terms of insurance coverage.
posted by dubious_dude at 5:42 AM on December 2, 2020 [3 favorites]

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