Health insurance for a rhinoplasty can be applied for
Plastic surgery: what the health insurance companies recognize as a disease
The World Health Organization (WHO) defines health as a state of complete physical and social well-being. Conversely, this means that almost everyone is sick. Such a concept of health cannot be in the sense of a social health insurance system. The Social Security Code V therefore only obliges the doctor to provide medically adequate and appropriate treatment; the obligation of health insurance is limited according to the law to the reimbursement of the necessary measures to protect, maintain, improve and restore health and performance.
According to § 12 paragraph 1 SGB V, unnecessary or uneconomical services are not included. However, the limits of "medical necessity" have shifted with medical advances. In the case of breast cancer, for example, reconstruction is now a natural, integral part of the treatment concept for breast cancer if the breast cannot be preserved. Medically necessary? Absolutely not: Breast reconstruction does not extend life expectancy by a day, has no influence on the prognosis, but exposes the patient to the unpredictability of further interventions.
Not so long ago there were voices against breast augmentation; the victim should be happy to have got away with her life. The psychological gain of a restored silhouette is no longer doubted by anyone today. Even for a so-called immediate breast reconstruction, i.e. amputation and reconstruction in one surgical session, there are hardly any contraindications, provided, of course, the patient so wishes.
This example clearly shows the rapid change in the understanding of what is medically necessary. At the same time, it shows that medical technologies meanwhile enable processes that expand the range of services. Against the background of the demographic change in the population structure, the problem of medical services that can no longer be financed on a permanent basis becomes apparent.
The legislature, which basically regards interventions to change the shape of the external appearance to the detriment of the insurance carrier as unjustified, has permitted exceptions. These concern:
- corrections to improve or restore the function,
- Corrections to improve or remove distortions. It must be added that corrections of physiological changes as a result of age, pregnancy, diet, abuse of addictive substances and other things are not medically indicated interventions.
The mental disorder
It is not uncommon to hear the argument that an annoying, external stigma leads to mental impairment, and this automatically justifies the obligation to reimburse. In a judgment of February 20, 1993 (Az .: 1 RA 14/92), the Federal Social Court found the following:
"If there is a mental disorder, it must be treated with the means of psychiatry and psychotherapy. In any case, the health insurance company's obligation to provide benefits does not include the costs for surgical interventions in a regular body condition in order to remedy or alleviate a mental disorder in this way.
This applies even if there is no other possibility of medical help due to the illness-related rejection of psychiatric, psychotherapeutic treatment. In the case of mental disorders that can be classified as dysmorphophobia, aesthetic surgery is even contraindicated in any case. . . "
Courtesy reports in favor of assumption of costs, in which psychiatric emergencies are constructed due to physiological disorders, ultimately damage the contribution payers and the medical profession, since the contributions and the capped budget have to serve for this.
The following is intended to illustrate the basic problem with a few examples. - Scar corrections: A 33-year-old patient is bothered by an older, retracted appendix scar that causes slight dysesthesia in the former wound area. According to the patient's feeling, this disfigures the stomach if he wears swimming trunks. !
This correction cannot be covered by the health insurance, as the scar is not disfigured a priori as a result of a physiological healing process. In most cases, neither aesthetic improvements nor the elimination of scarred dysesthesia can be achieved satisfactorily. According to relevant comments, the correction of a facial scar is only indicated medically at the expense of the health insurers if it has a disfiguring effect. In other parts of the body, especially over joints, it must be detrimental to function. In children, a scar (for example after being scalded) that leads to psychosocial conflicts can be reimbursed by the health insurances even if there is no malfunction. In the case of protruding ears, the decision is made in a similar way.
- Breast operations: A 56-year-old patient noticed that her breast had increased in size during the menopause and that the new, unusual fullness was disproportionate to the rest of the body silhouette. Hypertrophy of the female breast without any actual disease value is not a medical indication for reduction plastic at the expense of health insurance companies (Figure 1). Only in the case of mammary gigantomastias of considerable extent with stubborn intertriginal eczema formations in the folds of the breast envelope, painful BH lacing in the shoulder area or weight- or posture-related spinal damage does a "disease" require treatment within the meaning of the law. Depending on your constitution, it can be assumed that there is a medical indication if more than 500 grams per side have to be removed (rough guide).
- A 33-year-old female patient suffers from significant breast atrophy after two pregnancies. The desire to "refill" her former cup size leads her to the plastic surgeon. A congenitally small, slightly asymmetrical or physiologically sagging breast after pregnancy or age-related breasts is not a disease and cannot be corrected at the expense of health insurance companies. Only a clearly disfiguring breast aplasia or malformation of the breast may be removed by the statutory insurance company. The condition after a (partial) breast amputation is a disease within the meaning of SGB V. Reconstruction and follow-up operations (nipple, adjustments on the opposite side) are at the expense of the health insurance companies.
- Obesity interventions: A young, sporty patient disturbs the stubborn remaining fatty tissue in the buttocks area after a successful diet with a weight loss of five kilograms.
Eliminating obesity is generally not at the expense of the insurance carrier. Even if all other measures have been exhausted, localized remaining fat deposits or "cellulitic" bumps are not diseases that the insurance carrier would have to pay for the removal of these. The situation is different with the following example: A 24-year-old patient has consistently lost more than 80 kilograms from 180 to less than 100 kilograms, so that a classic "belly fat apron" has emerged, which in addition to difficult-to-treat fungal dermatoses, especially in summer, leads to urological problems when urinating can lead (Figure 2). After massive weight loss with consecutive intertriginous eczema and / or mechanical disorders or, for example, in the case of pathological elephantiasis, the surgical intervention is at the expense of the insurance carrier.
Pathological consequences of cosmetic surgery
There are no clear statements in the literature about the pathological consequences of aesthetic operations. In my opinion, follow-up interventions such as capsular contractures after implants or inpatient follow-up treatment due to postoperative incidents are part of the health insurance's obligation to provide benefits, as well as the consequences of smoking or extreme sports in the event of illness.
AOK Garmisch made a Solomonic decision with a patient whose silicone prostheses, which were used 15 years ago, hardened and were due to be operated on. She agreed to a removal and subsequent gathering to regain the shape of the breast, albeit a smaller one, but not to exchange new prostheses.
It is part of the doctor's task to provide his patients with realistic guidelines for what is reimbursable as a service from the health insurances according to the current state of the art. But he should also have the courage to decisively oppose the fully comprehensive mentality of some patients. The awareness is thus increasingly being created that not every medical service should automatically be replaced by the health insurances. The examples listed in the table are typical questions that arise most frequently in daily practice. Due to the variety of possible pathologies, this list cannot claim to be complete.
The reimbursement situation should be clarified in advance. Together with the medical service, the general practitioner and specialist and, if necessary, the psychiatrist, the course should be set so that the health insurance company is enabled to make a fair decision.
How this article is cited:
Dt Ärztebl 2000; 97: A-157-159
The bibliography is available in the offprint from the author and on the website (www.aerzteblatt.de).
Dr. med. Joachim Graf von Finckenstein
Plastic surgery specialist
Wittelsbacher Strasse 2a
Table correction of the external appearance and obligation of the statutory health insurance companies
(12 classic decision examples)
1 Scar correction NO
Exception: functional impairment or disfigurement, especially of the face and psychosocial problems in childhood
2 Removal of sagging facial skin NO
Exception: relaxation of the upper eyelids with a restricted field of vision from 10 ° when looking up; abnormal upper eyelid muscle tone; Sagging of the lower eyelids with pathological ectropion
3 Big ears sticking out YES
YES for children up to puberty if they lead to psychosocial problems, later NO; Ears are referred to as protruding if the conch / skull angle is greater than 45 °
4 rhinoplasty NO
Exception: external, disfiguring changes due to accidents or tumors; internal changes in the case of breathing difficulties (septum inclination or similar)
5 Breast Restoration YES
after cancer, in the case of malformation of the breast, etc.
6 breast augmentation NO
Exception: breast deficiency / reduced breasts
7 Breast reduction NO
Exception: giant breasts with an objectifiable clinical picture.
Non-binding benchmark: more than 500 g tissue removal per side
8 Tattoo removal NO
Exception: allergic reactions to the coloring, dirty tattoos
9 Skin tumor and skin spot removal YES
YES if there is a tendency to malignant degeneration; NO for annoying bumps and / or color schemes (e.g. freckles)
10 Liposuction NO
Exception: with pathological elephantiasis or with therapy-refractory, mechanical handicap
11 Removal of belly fat apron NO
Exception: significant mechanical complaints or persistent intertriginous eczema
12 Transsexuality YES
provided that the psychotherapy accompanied the everyday test for two years and was unable to prevent or tolerably alleviate the tension between gender identification and physical gender.
Figure 2: The dermolipectomy of an abdominal fat apron must be paid for by the health insurance companies if, for example, there are significant mechanical handicaps or intertriginal eczema that are refractory to therapy after severe weight loss. Photos: Starnberg District Hospital
Figure 1: Breast reduction surgery in a 56-year-old patient. The breast is big on both sides, but not pathologically hypertrophic, and therefore the health insurance companies are not obliged to cover the costs of the operation.
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