"Will my insurance cover this?" It arrives by WhatsApp several times a week, almost always with the answer already decided: the person assumes not, because the word in their head is "plastic".
That assumption shuts out a lot of people who did have something to claim. The line exists, but it does not fall where most people think.
The line is not cosmetic versus plastic
A plastic surgeon operates on both. An insurer does not classify by specialty: it classifies by purpose. The question a medical auditor asks is not who is operating, but what for.
If the operation restores a lost function or treats a disease, it is in reconstructive territory and there is something to argue. If it changes an appearance that works perfectly well, it is cosmetic and it does not qualify. The same scalpel, the same theatre and the same surgeon; two different categories.
What usually qualifies
- Breast reconstruction after cancer. Not a cosmetic add-on: it is part of the cancer treatment, and in Peru Law 31336 and its regulations frame it that way.
- Carpal tunnel and trigger finger. Functional hand surgery, with an objective diagnosis.
- Eyelids that block the visual field. Once upper-lid skin encroaches on vision, it stops being cosmetic eyelid surgery.
- Breast reduction for symptoms, with documented pain and conservative treatment already tried.
- Burn scars that contract and limit a movement.
- Hand trauma, replants, complex wounds and ulcers that will not close.
- Skin tumours, their removal, and the reconstruction of the defect left behind.
- Congenital differences: microtia, hand malformations, cleft lip and palate.
Falling into the category does not mean being approved. It means there is a case to put forward.
What almost never qualifies
Breast augmentation, liposculpture, rhinoplasty for cosmetic reasons, buccal fat removal, biostimulators, facelifts, buttock surgery. These operate on a body that works, and no insurer covers them.
One thing is worth saying plainly here. Every so often somebody asks whether a different diagnosis could not simply be written on the report. No. That is insurance fraud, with the patient's name and the doctor's signature on it, and both carry consequences. A surgeon who offers to word it that way is offering to land you in trouble.
What decides a claim is not the name of the operation. It is what was written in your medical record over the preceding months.
The grey area, where it is actually decided
Most cases sit in neither clean list but somewhere in between. And there the same operation can go either way depending on what is documented:
- Nose. A cosmetic rhinoplasty does not qualify. Correcting a deviated septum that stops you breathing does. If both are done together, each part is accounted for separately.
- Abdomen. An abdominoplasty for appearance does not qualify. A hernia, or an abdominal wall with a diastasis that causes symptoms, is assessed differently.
- Eyelids. What moves the decision is not the photograph: it is the visual-field test.
- Breasts. Neck and lower-back pain documented over months, with physiotherapy tried, is what separates a functional reduction from a cosmetic one.
The pattern repeats: what changes the answer is an objective test and a history. Not the way it is phrased.
The document to ask for
It is called a medical report, the surgeon writes it, and it is what the insurer reads. If it is incomplete, the claim is refused however strong the case. It has to include:
- The diagnosis with its ICD-10 code. Without a code the file does not even open.
- How long it has been going on and how it has progressed.
- What was tried first: splint, physiotherapy, injections, medication, and for how long.
- The objective tests. Nerve conduction studies for carpal tunnel, visual fields for eyelids, ultrasound or CT as applicable, clinical photographs.
- The proposed procedure, also coded, and why it is the right one.
- What function it restores. This is the sentence the auditor is looking for.
With that report you apply for the pre-authorisation letter. Always before the operation. Having the surgery first and claiming afterwards is the shortest route to paying for all of it.
Read your policy beforehand, not afterwards
Four things decide more than the diagnosis does, and hardly anyone looks at them until the bill arrives:
- Waiting periods. Months from the day you signed up during which certain operations are not covered.
- Pre-existing conditions. Whatever you already had when you signed up, declared or not. Declaring it always works out better than having it discovered later.
- Excess and co-insurance. Covered does not mean free: there is usually a percentage you pay.
- Network of clinics and doctors. Outside the network, the percentage changes or there is no cover at all.
Who decides, and what to do if they say no
The surgeon does not decide. The surgeon documents; the insurer's medical auditor approves or refuses. Anyone promising you cover in advance is promising something that is not theirs to give.
If you are refused, ask for the refusal in writing, with the reason. With that letter the decision can be reconsidered, and the reason is often fixable: a missing test, not enough time on conservative treatment, a missing code. If the answer still does not convince you, there are places to take it — your insurer's policyholder ombudsman, the SBS, Indecopi — and within EsSalud the route is its own member services office.
The timescales run to weeks, not days. Which is why this conversation belongs to the moment you decide to have surgery, not the moment you have a date.
What you can do from today
If you suspect your case is functional, the thing that helps most is the dullest: get it written down. Make sure every consultation about the pain, the tingling or the limitation appears in your record. Make sure the physiotherapy has a discharge report. Make sure the tests are done and kept.
A case is built over months. The day you request the pre-authorisation letter, all you can gather is what was already there.