medically necessary reconstructive surgery

I just wanted to know if there was anyone out there who has RMSCO insurance and has gotten approved for the abdominoplasty or breast reduction (or anything else for that matter). I have been having severe back, neck and shoulder pain for the last month or more and have an appointment to go see my PMD this Friday. People are telling me that it is because of my breasts being too large for me now and the insurance company might pay for a reduction and lift as long as it is medically necessary. So, the back, neck and shoulder pain make it medically necessary. I also get rashes on my breasts. Also, I have been having rashes on my belly and now just found out that the pain I have been having in my mid belly, near my belly button, is a new umbilical hernia. I have been told that the insurance company might also pay for my abdominoplasty if it is medically necessary, and that those reasons make it medically necessary. I have lost 155 pounds so far and it has been almost 9 months since my surgery. I have also heard that you have to be a minimum of one year out before they will even think about doing any kind of reconstruction surgery. Is that true? I am about 48 pounds from my goal weight. Any information regarding this would be greatly appreciated. Thanks.

Hi, I think you definitely fall under the category for a breast reduction, question is, will your insurance co. pay. A breast reduction is considered reconstructive, when you go to a plastic surgeon they will document your pain and rashes, take pics (not pretty lol) and send that in to the insurance co. My insurance took maybe 2 weeks to approve. I had my reduction last week and so far so good. A breast lift I believe is considered more cosmetic than reconstructive, but I could be wrong. It also sometimes goes by how many grams your doc says he needs to remove from each breast. For me it was 500 grams each, which is a little over a pound each. Alot of that was skin, so I think I gave my doc a good workout. Start with making some appts (consultations might be covered by your insurance) with some good qualified docs in your area that have experience doing reductions. Good Luck! A good web site to check out: www.breasthealthonline.org

Hi Cheeky. Thank you for the information. Do you have any idea about the abdominoplasty. With rashes and umbilical hernia, a lot of people have said that those are reasons of medical necessity and that the insurance would cover that. I think that maybe even the hanging belly might also be contributing to some of my back pain as well as the hanging boobs.

Yup, that too. Basically, as soon as you list a rash and pain as two reasons and have documented proof from your doctor, that gets submitted for approval. The thing is, your specific insurance plan needs to have it listed as something they will cover. I would think they would also consider the fact that you had gastric bypass and that this is the second phase of that. You can call your insurance company and ask them specifically, sometimes it also depends on what your job agreed to have the insurance cover, you can have 2 people with the same insurance but have different things paid for from their jobs. So you can call the insurance company or go to a plastic surgeon and let him submit it for you.