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hould insurance cover breast augmentation, the procedure commonly known as a boob job?

Most people would say “no, of course not.” That’s a cosmetic procedure, and health insurance shouldn’t pay for a procedure done to make someone look better. But what if it is part of breast reconstruction after breast cancer surgery, or part of gender reassignment surgery for a transgender patient?

That’s different, they might say.

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Sometimes there’s a fine line between a cosmetic procedure and a medically necessary one. As a society, we have decided that most cosmetic procedures are elective and thus should be paid for by the individuals having them, while medically necessary procedures are covered by insurance. This makes it difficult for people who want to have surgery for conditions that fall in the gray zone between cosmetic and medically necessary, difficult for the doctors who take care of them, and a challenge for insurers whose goal is to minimize their expenses.

At the core of this issue is how we define the terms cosmetic and medically necessary. The traditional distinction is that cosmetic treatments are merely enhancements that improve appearance, while medically necessary treatments address a disease and are necessary for health or survival. But this distinction can be arbitrary.

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Further complicating matters is the role that health care plays in our lives. One important role, to be sure, is to preserve and extend people’s lives or, in the language of medicine, to reduce mortality and morbidity. Those outcomes are relatively easy to measure. But health care should also strive to improve something that’s less easily defined: quality of life. Most people live long lives these days but many of them also develop chronic health problems, despite the pace of medical advances. We are living longer than ever, but not necessarily better.

Here’s a common example from my dermatology clinic. A patient waits months for an appointment. When I finally see her, she points out a skin tag in her right armpit. This benign, polyp-like growth has bothered her for years — she often nicks it while shaving, it rubs against her clothes, and it occasionally becomes painful and irritated.

After I examine the patient and her skin tag, I am confident that it is not a type of cancer and does not threaten her health or life. But that doesn’t solve the problem. Here’s my dilemma as her doctor: If I remove the skin tag to improve her quality of life, she will almost certainly have to pay for the procedure because her insurance company will deem it cosmetic. But if I remove the skin tag and then send it to a pathologist to evaluate, her insurance will pick up the cost because the removal can be justified as necessary to prove it wasn’t skin cancer.

I find it ironic that performing an extra evaluation (at extra cost) to confirm that the skin tag was benign adds credibility to my claim that its removal was medically necessary. At what point does performing a biopsy of tissue that is conspicuously normal, in the service of taking care of patients, become fraud?

Nothing is 100 percent in science or medicine. I don’t want to miss a skin cancer, and though it’s rare, I’ve seen normal-looking skin lesions turn out to be cancers. This could give me license to biopsy everything, but that approach isn’t cost-effective and ignores the complications that biopsies can cause, such as scars, infected wounds, and the like. But as I strive to provide excellent care to my patients, I must often advise them against treatment for conditions that mainly affect their quality of life unless they can pay for it out of pocket.

More and more I find myself arguing with insurance companies to cover treatment of my patients’ skin conditions that are seriously affecting their quality of life. I fill out countless prior authorization forms and regularly talk peer to peer with medical representatives, advocating for my patients. In addition to irritated skin tags, insurers also often don’t want to pay for steroid injection treatments for the painful overgrowing scars known as keloids, for the autoimmune hair loss known as alopecia areata, and even for painful cysts that form in the underarms or folds in the skin (hidradenitis suppurativa). These conditions and others can deeply affect an individual’s quality of life. Yet I am frequently told that I have not sufficiently proven that.

To be clear, I don’t believe that health insurance companies should give patients carte blanche to have any and all cosmetic concerns treated and to have the costs shared by others in the insurance pool. It’s entirely reasonable to create a set of priorities for how we spend our health care dollars. However, I think insurance companies’ priorities on what they will pay for do not necessarily match what can make real differences in people’s lives.

Our health care system spends a disproportionate amount of money taking care of patients during their last months of life. In one study, 30 percent of Medicare dollars were spent on the 5 percent of people who died in a year, with another study showing one-third of the expenditures in the last year of life being made during the last month.

I do not want to minimize the importance of end-of-life care, and it may not be entirely clear that the end of life is near when that money is being spent. But from a purely utilitarian perspective, does it make the most sense to be spending so much money on end-of-life care and so much less on actively improving the quality of life of those with decades left?

It is impossible to value one person’s life over another’s, nor should we try to do that. But I think that we must not undervalue the importance of addressing conditions that affect quality of life.

There is a growing body of evidence that treatment of supposed “cosmetic” concerns can have a real and positive effect upon quality of life. Facial cosmetic surgery, for example, has been associated with modest improvements in quality of life, self-esteem, and body image. In addition, better quality of life is likely to improve patient satisfaction, which is increasingly (if controversially) being used to measure the value of health care.

While lifesaving treatments are always a priority, I believe that doctors today should also try to improve their patients’ quality of life, and measures that do that should be paid for by insurance. Placing more value upon quality of life and working to preserve it should be paramount, and valuing patient complaints that some may dismiss as merely “cosmetic” is among the first steps to address this.

Jules Lipoff, MD, is assistant professor of clinical dermatology at the University of Pennsylvania.

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