Medical Policy

Cosmetic vs. Reconstructive Services

There is a significant difference between cosmetic and reconstructive procedures. Cosmetic procedures are almost always excluded from benefit coverage, while reconstructive procedures may be considered eligible for coverage, based either on associated medical necessity or on the specific benefits language describing reconstructive services. While it can be argued that there is inherent subjectivity in some decisions and that all cases must be individualized, it is the desire of Clinic’estetica™ to differentiate between cosmetic and reconstructive procedures in a rational, consistent, and externally-validated manner.

Cosmetic services are designed to improve or enhance a physical appearance by reshaping or improving the appearance of normal (including aging) tissues. Since there is a considerable variation of physical characteristics in the population, procedures that attempt to significantly change or refine normal variation to a more “idealized” shape are still considered cosmetic.

Reconstructive services are intended to restore the normal appearance or function of tissues that have been significantly altered due to disease, trauma, surgery or congenital anomalies (a feature is anomalous if it is outside the range of normal human variation). When a significant functional impairment is present, reconstructive services may be considered MEDICALLY NECESSARY .

When a significant functional impairment is not present, reconstructive services may be considered NOT MEDICALLY NECESSARY, but nevertheless still may be eligible for coverage. Each instance depends on the specific benefits language and/or state mandate describing the scope of coverage eligibility for reconstructive services.

Your Health Information

At Clinic’estetica™ we are committed to keeping your personal health information private, and we are also required by law to respect your confidentiality. We use your health information to provide you with health care services and we may disclose your health information to doctors, nurses, technicians, medical or nursing students, or other persons at Clinic’estetica™ who need that information to take care of you.

We do not disclose any information about you to anyone or to any organization without your prior consent. If your insurance company requests information, we will only respond after you have given your consent for us to do so.

Contacting You

We may need to reach you about appointments and other matters, and may contact you by mail, telephone or email. You should advise the Clinic if we may leave a message at the contact number you have provided and give us a secure email address as well. We respect your desire for confidentiality, but must have a way of personally communicating with you.

Health-Related Services

We may use your health information to send you mailings about health-related products and services available at Clinic’estetica™.

Medical Research

Clinic’estetica continues to perform medical research, and our researchers may look at your health records as part of your current care or to gather data for research..

Legal Matters

We will disclose health information about you to parties outside Clinic’estetica™ when required to do so by federal, state, or local law, or by the court process.