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EPS are required to cover cosmetic procedures for reconstructive or functional purposes

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EPS are required to cover cosmetic procedures for reconstructive or functional purposes

In a recent ruling, the Constitutional Court of Colombia reaffirmed that aesthetic medical procedures for functional or reconstructive purposes are covered by the country’s health system and that Health Promotion Entities (EPS) have the obligation to provide this coverage to patients that require it.

The Court established that functional aesthetic surgeries can be requested by users to their respective EPS when they have a medical order that requires it. In addition, he emphasized that the entities cannot deny the provision of these services based solely on their exclusion from the Health Benefits Plan, unless they demonstrate, through medical concepts in the study of each specific case, that the requested procedures They have exclusively aesthetic and non-functional reconstructive or emotional, psychological and social well-being purposes.

The decision was made after studying a guardianship filed by a woman who suffers from sagging skin as a result of previous medical treatments to combat morbid obesity. According to the diagnosis of a health professional not attached to the EPS to which the plaintiff belonged, the patient required to undergo a breast reduction.

Despite the medical recommendation, the Cesar Health Department and the EPS refused to authorize the procedures, arguing that they were cosmetic surgeries not included in the Health Benefits Plan. The plaintiff insisted that these procedures were necessary to improve her health and relieve irritation caused by excess skin, in addition to dealing with emotional and depressive problems derived from her condition. However, the EPS did not present an adequate medical diagnosis to support its refusal.

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The Second Review Chamber of the Constitutional Court found that the EPS had not made an adequate medical diagnosis to justify the denial of the requested services. The Court stressed that it was necessary to evaluate each case individually and determine if the required medical services had a functional or reconstructive purpose, instead of being merely aesthetic.

As a result, the Court upheld the plaintiff’s fundamental right to health in terms of diagnosis and ordered the EPS to carry out a comprehensive medical examination to determine the origin of the required surgical procedures, taking into account scientific criteria and respecting the informed consent of the patient.

In addition, the Court warned the EPS that it must guarantee the right to health of people who request these functional and reconstructive procedures, prescribed by doctors not linked to the entity. In such cases, the EPS must carry out a prior and comprehensive evaluation of the patients.

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