What Are Elective Procedures and How Do Insurers Define Them?
By Krista DeKuyper | March 27, 2025 |
Elective procedures, also known as elective surgery, are difficult to navigate in the world of insurance. Although they effectively improve one’s quality of life, their medical necessity is commonly debated. This often leads to unexpected gaps in coverage. Not all elective surgeries are covered by your insurance provider, but many can be under the right circumstances. We’ll uncover what elective procedures are and how to determine whether they’re subject for coverage. We’ll also provide helpful guidance for getting your elective surgery approved by your insurance provider.
What Are Elective Procedures?
Elective procedures are surgeries that aren’t an emergency and don’t address a specific life-threatening issue. Elective surgeries aim to improve a person’s quality of life. Examples of elective surgeries include:
- Bariatric surgery
- Tonsillectomy
- Joint replacement
- Hernia repair
- Cataract surgery
Each of these procedures have an effect on the patient’s quality of life, but are not necessary for the patient to live.
Additionally, there is semi-elective surgery. Semi-elective surgery is performed to save a person’s life but is not an emergency. A surgery is considered semi-elective when the patient’s condition is projected to worsen but does not need immediate intervention. The surgery is scheduled days, weeks, or months in advance.
How Do Insurers Define Elective Procedures?
Insurers typically cover elective surgeries that are deemed medically necessary. While the procedures are not emergencies, many insurance providers recognize the importance of elective surgeries. To qualify for insurance coverage, however, certain criteria must be met:
- Documentation: Generally, insurers try to understand the medical necessity of an elective procedure. Despite that, some procedures require more documentation than others for approval. Your provider might reject your claim if there are other treatments of the same condition. For approval, your doctor needs to provide a detailed recommendation letter for the procedure. This letter includes medical history, previous treatments, and the effects of other treatments. Additionally, your doctor should explain why the elective surgery is the best option.
- Insurance Policy Details: The surgery needs to be listed as applicable for coverage in your policy. Carefully review your health insurance plan to confirm what is covered. If the procedure is not eligible, a recommendation letter from your doctor will help your case.
What’s Covered vs. What’s Not
We’ve compiled a list of some of the most commonly covered elective procedures. This list should give insight into whether your desired elective procedure is eligible.
Commonly Covered Elective Procedures
- Joint replacement
- Cataract removal surgery
- Bariatric surgery for obesity treatment
- Surgical procedures to manage chronic pain
- Facial reconstruction surgery after trauma
Excluded Elective Procedures
- Cosmetic surgeries purely for aesthetic reasons (not deemed medically necessary)
- Experimental or investigational procedures
- Minimally invasive procedures that are not covered under the specific plan
- Surgeries that do not improve quality of life in ways recognized by insurers
- Some providers will not cover laser eye surgery
- Some providers will not cover infertility treatment
Navigating Insurance For Elective Procedures: Tips for Patients
- Understand Your Policy: Familiarize yourself with your health insurance policy and its coverage. Your policy will describe specific scenarios where each elective surgery is eligible for coverage.
- Consult Your Healthcare Provider: Healthcare providers have extensive experience working with insurance providers to secure coverage for their patients. Let your doctor know about your concern for coverage and ensure that they document the necessity of the procedure adequately. Don’t be afraid to ask for a letter of recommendation when needed.
- Pre-Authorization: Many plans require prior authorization for elective surgeries. You should obtain authorization before the surgery to avoid claim denial. Reach out to your insurance provider for clearance beforehand.
- Keep Records: Maintain thorough records of all discussions, recommendations, and communications. Keep records from both your healthcare provider and insurance company. This is crucial in case of disputes over coverage.
- Explore Alternative Options: When the procedure you need is not covered, inquire about alternative treatments. There are often other options that are better covered under your plan.
Find Elective Surgery Coverage with HealthQuotes
Do you find yourself dissatisfied with your current insurance’s elective coverage options? Consider switching to a provider with better coverage for elective procedures. At HealthQuotes, our team of insurance agents will guide you through the process of finding the right plan for your needs. We’ll work with you to find an insurance plan that covers your desired elective surgery.
Contact us today for a free consultation and ensure that you receive the care you deserve without unexpected costs!
