For Medicare, the difference is clearly marked. The Reconstructive surgery, born from the reconstruction of the “broken mouths”, following the ravages of the First World War, aims to restore integrity to a damaged face or body. Considered therapeutic, it is taken care of, unlike the plastic surgery, an “accessory surgery” which is not based on medical reasons. But the border is sometimes thin, the two disciplines being moreover united within the same surgical specialty.
“In all reconstructive surgery, there is an aesthetic notion and in all cosmetic surgery, there is a dimension of suffering and discomfort which requires treatment”, underlines Dr. Sébastien Garson.
Facial plastic surgery
The intervention is reimbursed if it remodels the nasal septum. A deviated nasal septum is always the consequence of a trauma, a shock, a fight, a road accident, or even a congenital malformation causing respiratory discomfort. On the other hand, a rhinoplasty to correct a nose that is too long, too wide, or too big is not. “An operation to correct a bump on the nose, of non-traumatic origin, is not reimbursed, even if it causes a large complex”, regrets Dr. Garson. In the event of breathing disorders, however, you can submit a request for prior agreement to Social Security.
It is a congenital malformation. The operation which consists of reattaching them (otoplasty) is taken care of in children as well as in adults, from the moment when it causes a significant complex in the young subject or a social discomfort in the adult. These criteria are subject to the appreciation of the plastic surgeon. The chin in galoche or very elusive: the people concerned can be very complexed, but the operation is supported, with prior agreement, only if the disharmony leads to a maxillofacial problem.
Lifting, eyelid surgery, injections of fat, Botox, or hyaluronic acid are not reimbursed.
Plastic surgery operations on the body
- All the breast reconstructions after breast cancer are supported regardless of the method used.
- The breast reduction is also exempt from the prior agreement, provided that “the removed part weighs at least 300 g per breast, specifies Dr. Garson. In most cases, we are sure to remove this weight, but we also sometimes give two quotes to a patient, one with reimbursement, the other without, in the event that the part removed does not. would not reach 300 g ”. “Surgeons are rarely wrong in their estimates,” observes a Medicare consultant. But if, in the end, about 290 g per breast were removed, the reimbursement is not in question. This flexibility may however vary from one fund to another, depending on the medical adviser and his assessment.
- The breast augmentation are reimbursed, after prior agreement, only in three situations: the cup size is less than A, the breasts are tuberous (tube-shaped) or the asymmetry is very marked, corresponding to at least one cup gap.
- the sagging breast lift, even after pregnancy, is not reimbursed.
To read also: Sublimate her chest and cleavage!
THE’tummy tuck is an operation that consists of tightening and removing the excess skin in the abdomen. Whatever the origin (severe weight loss, pregnancy (s) …), it is reimbursed, after prior agreement, if the skin covers part of the pubis.
To read also: Abdominoplasty: to find a flat stomach
Whether it is for the arms, legs or buttocks or even liposuction, only procedures following significant weight loss, after obesity surgery in particular, can be reimbursed with prior agreement.
All burns, bites and scars caused by illness or accident are covered. If it is (pre) cancerous, the removal of a mole may be reimbursed.
Cosmetic surgery: the average prices practiced and the basis for reimbursement
- Average price with excess fees *: € 1,000 to € 2,500
- Social Security reimbursement base **: 175 to 347 €
- Average price with excess fees *: 800 €
- Social Security reimbursement base **: € 236
- Average price with excess fees *: € 2,000
- Social Security reimbursement base **: € 303
- Average price with excess fees *: € 1,900
- Social Security reimbursement base **: € 408
- Average price with excess fees *: 900 to 1,000 €
- Social Security reimbursement base **: 175 to 252 €
- Average price with excess fees *: € 1,800
- Social Security reimbursement base **: € 346
Silhouette surgery (Bodylift)
- Average price with excess fees *: € 2,900
- Social Security reimbursement base **: € 423
Skin operation (Bodylift)
- Average price with excess fees *: 100 to 300 €
- Social Security reimbursement base **: € 28 to 155
* Data provided by the National Syndicate of Plastic, Reconstructive and Aesthetic Surgery. ** The social security reimbursement base includes the surgery and anesthesia.
Reimbursed plastic surgery: the prior agreement, how does it work?
In the case of an operation reimbursed without prior agreement, a well-documented file is sufficient to trigger the coverage. Conversely, the answer depends on the assessment of Medicare. The process then takes place in 5 steps:
- The surgeon makes the request for reimbursement by form.
- The patient sends the form to his primary health insurance fund by registered mail with acknowledgment of receipt.
- Failure to respond within 15 days of receipt of the letter means that the reimbursement is validated by the organization. Plastic surgeons, however, warn patients against this principle and advise them to revive Medicare.
- A summons may be sent by the Medicare consultant to schedule a clinical examination. This allows you to check whether the act is eligible for reimbursement.
- In case of refusal, an appeal can be made within 2 months of receiving the decision. New expertise will be carried out by a plastic surgeon appointed by Social Security.