Cosmetic vs Medical: When Insurers Wrongly Classify Your Treatment

"That's a cosmetic procedure. Not covered."

You hear this from insurance, and it feels wrong. Your nose breathing problem is real. Your eyelid vision obstruction is real. You're not getting this procedure to look better—you're getting it to function better.

Insurance is misclassifying your procedure as cosmetic when it's actually medically necessary. This is one of the most frequently reversed denials when appealed correctly.

The Cosmetic vs. Medical Problem

The challenge: Many procedures have both cosmetic and medical purposes. A rhinoplasty improves breathing (medical) and appearance (cosmetic). A blepharoplasty restores vision (medical) and improves appearance (cosmetic). A gum surgery removes diseased tissue (medical) and improves appearance (cosmetic).

Insurance often focuses on the appearance improvement and denies the claim as cosmetic. But if the primary purpose is medical, the procedure should be covered.

Legal Standard: Primary Purpose Matters

Courts and regulators use a consistent standard: Is the primary purpose of the procedure medical or cosmetic?

• Primary purpose is medical (restoring function, treating disease, eliminating pain) = Should be covered
• Primary purpose is cosmetic (improving appearance as the main goal) = Not covered

The fact that the procedure improves appearance is irrelevant if the primary purpose is medical.

Common Misclassified Procedures

Rhinoplasty (Nose Surgery)

Insurance often denies rhinoplasty as cosmetic. But many are medically necessary for:

• Deviated septum causing breathing obstruction
• Nasal valve collapse
• Sleep apnea
• Obstructive sleep apnea caused by nasal obstruction

How to appeal: Get your ENT physician to document:

• The specific breathing problem (objective findings from sleep study, spirometry, etc.)
• How the septum deformity is causing the obstruction
• How rhinoplasty will restore function
• That breathing restoration, not appearance, is the goal

"While rhinoplasty changes appearance, the primary purpose is restoring nasal breathing function. My [objective finding] documents significant breathing obstruction. My ENT has determined that this breathing problem directly affects my quality of life and health. Surgical restoration of breathing function is medically necessary."

Blepharoplasty (Eyelid Surgery)

Insurance denies as cosmetic. But it's medically necessary for:

• Ptosis (drooping eyelid) obstructing vision
• Entropion or ectropion (eyelid malposition) causing irritation
• Excessive eyelid skin blocking peripheral vision
• Eyelid lesions requiring removal

How to appeal: Get your ophthalmologist to document:

• The specific vision problem (measured by visual fields, photographs, etc.)
• How the eyelid condition is causing it
• How surgery will restore vision
• That vision restoration, not appearance, is the goal

"While blepharoplasty changes appearance, the primary purpose is restoring visual function. My ophthalmologist's testing documents [specific vision deficit]. Surgery will restore my peripheral vision and eliminate visual obstruction. Medical restoration of vision, not cosmetic improvement, is the goal."

Gum Surgery (Periodontitis Treatment)

Insurance denies as cosmetic. But it's medically necessary for:

• Treating periodontal (gum) disease
• Preventing tooth loss
• Treating gum recession
• Removing diseased tissue

How to appeal: Get your periodontist to document:

• The gum disease diagnosis
• Why surgical treatment is necessary (not just cleaning)
• What consequences untreated disease would cause (tooth loss, infection)
• That disease treatment, not appearance improvement, is the primary purpose

"Gum surgery is treating periodontal disease, not improving appearance. My periodontist's clinical examination documents [specific disease findings]. Without surgical intervention, I face [specific consequences: tooth loss, infection]. Surgical treatment of active disease is medically necessary."

Dental Veneers for Discolored or Fractured Teeth

Insurance denies as cosmetic. But they may be medically necessary for:

• Restoring function after significant tooth damage
• Covering exposed dentin (causing pain)
• Replacing failed restorations

How to appeal: Get your dentist to document:

• The reason for the discoloration/damage (accident, root canal, decay, etc.)
• Functional problems (pain, sensitivity, inability to chew)
• Why veneers are necessary (not just cosmetic preference)
• That functional restoration, not appearance, is the primary goal

"Veneers are necessary to restore tooth function, not purely for cosmetic reasons. My tooth [fractured/became discolored after root canal], causing [functional problem]. Veneers will [restore function/eliminate pain/allow normal chewing]. Functional restoration is the primary purpose."

Scar Revision

Insurance denies as cosmetic. But it may be medically necessary for:

• Scars that restrict movement (contractures)
• Scars causing pain
• Scars that prevent normal function
• Trauma-related scars needing revision for healing reasons

How to appeal: Get your plastic surgeon to document:

• The scar's impact on function (movement restriction, pain, etc.)
• Why revision is medically necessary
• That functional improvement, not cosmetic preference, is the goal

"Scar revision is medically necessary to restore function, not for cosmetic improvement. The scar [restricts movement/causes pain/prevents normal function]. Surgical revision will [restore range of motion/eliminate pain/restore function]. This is medical treatment, not cosmetic."

Building Your Cosmetic vs. Medical Appeal

Your appeal should reframe the procedure around its medical purpose, not appearance.

Opening

"I am appealing [Insurance]'s denial of coverage for [procedure] on the grounds that it is cosmetic. This procedure is medically necessary because [specific medical reason], not purely cosmetic."

The Medical Purpose

Focus on function and health, not appearance:

• What medical problem does the patient have?
• How does the problem affect function, health, or quality of life?
• How does the procedure treat that problem?
• What is the expected medical outcome?

Example: "I have a deviated septum causing significant breathing obstruction. This obstruction affects my sleep quality, energy, and overall health. Rhinoplasty will surgically correct the obstruction and restore normal breathing function."

Note: No mention of appearance. All focus on breathing function.

Get Medical Objective Evidence

This is critical. Get:

• Test results documenting the problem (sleep study, pulmonary function test, visual field test, etc.)
• Clinical photographs documenting the problem (not for appearance, but for medical documentation)
• Objective measurements of the dysfunction
• Physician documentation of the impact on health/function

Get Your Physician's Statement

Your treating physician must write:

"This procedure is medically necessary because [specific medical problem]. The patient has objective evidence of [specific finding]. The primary purpose of the procedure is [medical goal: restoring function, eliminating pain, treating disease]. While the procedure may improve appearance, appearance is not the primary goal. Medical necessity, not cosmetic preference, supports this treatment."

Address the Insurance Objection

Insurance says it's cosmetic. Your response:

"While [procedure] may incidentally improve appearance, that is not its primary purpose. The primary purpose is [medical purpose]. My physician's objective findings document [specific dysfunction]. The procedure will treat [specific medical problem] and restore [specific function]. This is medical treatment, not cosmetic."

Use Policy Language

Quote your policy if it supports coverage of function-restoring procedures:

"My policy covers [treatments for breathing problems/vision problems/disease treatment/etc.]. This procedure treats [specific medical problem], which falls clearly within coverage."

Timeline: Act Quickly

Insurance may be quicker to deny cosmetic procedures, but they should approve once they understand the medical purpose. Act fast:

• Appeal within 1-2 weeks of denial
• Ensure your physician's letter is attached
• If insurance denies your appeal, escalate within weeks

When to Escalate

If insurance maintains the cosmetic classification denial:

• Escalate to your regulator (state insurance commissioner, FOS, AFCA, etc.)
• Argue that insurance wrongly classified a medically necessary procedure as cosmetic
• Provide objective medical evidence supporting the medical necessity

Getting Help Challenging Cosmetic Classifications

The key to winning cosmetic vs. medical appeals is reframing the procedure around its medical purpose while providing objective evidence of the medical problem. You need to present your situation in clinical/functional terms, not appearance terms, and ensure your physician's support is strong.

ClaimBack's AI helps you gather objective evidence, frames the medical purpose compellingly, coordinates with your physician, and drafts an appeal that challenges the cosmetic classification based on medical evidence.

Get your free cosmetic vs. medical appeal analysis →

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Disclaimer: ClaimBack provides AI-generated appeal assistance for informational purposes only. ClaimBack is not a law firm and does not provide legal advice. Always review your appeal letter before sending and consider professional advice for complex or high-value claims.

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