Summary Plan Description

Reconstructive Surgery

90% Network and 80% Non-Network
Services and Supplies Must Be Precertified Unless the Patient Is a Medicare-Eligible Retiree

Benefits are provided for services and supplies provided by a physician for reconstructive surgery, meaning any operative procedure, any portion of an operative procedure or any other treatment performed for the purpose of improving or restoring a functional impairment which is defined as a state in which the special, normal or proper action of any body part or organ is damaged.

Benefits are not provided for cosmetic surgery (including any direct or indirect complications) meaning any operative procedure, any portion of an operative procedure or any other treatment performed primarily for the purpose of improving or reshaping structures of the body in order to enhance the patient's appearance and self-esteem, and is not needed to correct or improve a bodily function. The following examples of what are not covered: surgery for sagging skin of the eyelids (blepharochalasis), face, neck, abdomen, hips, or extremities (meloplasty, rhytidectomy or lipectomy); breast augmentation, cosmetic reduction or uplift procedures; gynecomastia; reshaping of the nose (rhinoplasty) or ears (otoplasty); or silicon or collagen injections; or cosmetic laser procedures to any part of the body.

Reconstructive Breast Surgery

Benefits are provided for services and supplies provided by a physician related to initial reconstructive breast surgery following or coinciding with a mastectomy that is performed as a result of an illness or injury. In accordance with the Women's Health and Cancer Rights Act of 1998, such benefits include reconstruction of the breast on which the mastectomy was performed, surgery on the other breast to produce symmetrical appearance, and prosthesis and treatment of physical complications at all stages of mastectomy, including lymphedemas. One external prosthesis is covered each calendar year and two mastectomy bras are covered every six months.

Breast reconstructive surgery to correct breast asymmetry is not considered medically necessary except for:

  • Poland syndrome, in conjunction with surgical correction of chest deformity; or
  • Repair of breast asymmetry due to a medically necessary mastectomy; or
  • Prompt repair of breast asymmetry due to trauma.

Benefits are not provided for reconstructive breast surgery for complications arising from a cosmetic procedure such as augmentation or reduction mammoplasty.