HAS ANYONE GOT INSURANCE TO PAY FOR PLASTICS?
Plastic surgery is cosmetic and likely not covered by almost all insurance companies. Only exception I can think of is breast reconstruction from cancer. My insurance company will pay for breast size reduction or the "panni", where excess abdominal skin is just cut off. These later surgeries are not like plastic surgery with hidden sutures, tightening muscles, etc. Panni surgery pateint often wake up with no belly button. You also have to qualify for these surgeries with plenty of documentation from your PCP--photos, office calls for rashes or skin fungal issues, history of scripts to deal with these issues, etc. A local plastic surgeon does accept part of my insurance panni surgery bill for a tummy tuck. Fees for operating room and anesthesia services are paid to the plastic surgeon, so your fees are reduced by about two thousand dollars. It's something, but you still have a bill you have to pay for the balance of the plastic surgery. DAVE
Dave Chambers, 6'3" tall, 365 before RNY, 185 low, 200 currently. My profile page: product reviews, tips for your journey, hi protein snacks, hi potency delicious green tea, and personal web site.
Jeez, once again, Dave, you're wrong, especially in California.
First of all, your blanket statement that reconstructive surgery is cosmetic is simply WRONG. Reconstructive surgery is a subset of plastic surgery and is by definition not MERELY cosmetic.
Second, if medical necessity for a procedure can be established, e.g., for intractable intertrigo, functional impairment, etc., ANY insurance company can be forced to cover reconstructive surgery.
Third, you don't know California law.
The California Health and Safety Code 1367.63 mandates that health care service plan contracts issued or delivered in California on or after July 1, 1999 cover reconstructive surgery that is necessary to achieve the purposes specified in paragraphs (1) or (2) (note: in the alternative, not conjunctive) of subdivision (c) of that section:
1367.63. (a) Every health care service plan contract, except aspecialized health care service plan contract, that is issued,amended, renewed, or delivered in this state on or after July 1, 1999, shall cover reconstructive surgery, as defined in subdivision (c), that is necessary to achieve the purposes specified in paragraphs (1) or (2) of subdivision (c). Nothing in this section shall be construed to require a plan to provide coverage for cosmetic surgery, as defined in subdivision (d).
(b) No individual, other than a licensed physician competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for treatment pursuant to this section. For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed individual, competent to evaluate the specific clinical issues involved in the care requested.
(c) "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:
(1) To improve function.
(2) To create a normal appearance, to the extent possible.
(d) "Cosmetic surgery" means surgery that is performed to alter or reshape normal structures of the body in order to improve appearance.
(e) In interpreting the definition of reconstructive surgery, a health care service plan may utilize prior authorization and utilization review that may include, but need not be limited to, any of the following:
(1) Denial of the proposed surgery if there is another more appropriate surgical procedure that will be approved for the enrollee.
The California Health and Safety Code 1367.63 mandates that Health Net (as a provider of a health care service plan contract issued or delivered in California on or after July 1, 1999) cover reconstructive surgery that is necessary to achieve the purposes specified in paragraphs (1) or (2) (note: in the alternative, not conjunctive) of subdivision (c) of that section:
1367.63. (a) Every health care service plan contract, except aspecialized health care service plan contract, that is issued,amended, renewed, or delivered in this state on or after July 1, 1999, shall cover reconstructive surgery, as defined in subdivision (c), that is necessary to achieve the purposes specified in paragraphs (1) or (2) of subdivision (c). Nothing in this section shall be construed to require a plan to provide coverage for cosmetic surgery, as defined in subdivision (d).
(b) No individual, other than a licensed physician competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for treatment pursuant to this section. For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed individual, competent to evaluate the specific clinical issues involved in the care requested.
(c) "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:
(1) To improve function.
(2) To create a normal appearance, to the extent possible.
(d) "Cosmetic surgery" means surgery that is performed to alter or reshape normal structures of the body in order to improve appearance.
(e) In interpreting the definition of reconstructive surgery, a health care service plan may utilize prior authorization and utilization review that may include, but need not be limited to, any of the following:
(1) Denial of the proposed surgery if there is another more appropriate surgical procedure that will be approved for the enrollee.
(2) Denial of the proposed surgery or surgeries if the procedure or procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, offer only a minimal improvement in the appearance of the enrollee.
(3) Denial of payment for procedures performed without prior authorization.
(4) For services provided under the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), denial of the proposed surgery if the procedure offers only a minimal improvement in the appearance of the enrollee, as may be defined in any regulations that may be promulgated by the State Department of Health Services.
(2) Denial of the proposed surgery or surgeries if the procedure or procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, offer only a minimal improvement in the appearance of the enrollee.
(3) Denial of payment for procedures performed without prior authorization.
(4) For services provided under the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), denial of the proposed surgery if the procedure offers only a minimal improvement in the appearance of the enrollee, as may be defined in any regulations that may be promulgated by the State Department of Health Services.
~~~
Morbid obesity is a disease. Many of our post-weight loss skin laxity issues constitute abnormal structures of the body. If you can get a plastic surgeon to prepare a letter requesting authorization for these procedures, stating that in his opinion, you have abnormal structures of the body, caused by the disease of morbid obesity and the treatment for that disease, for which reconstructive surgery procedures can improve appearance to the extent possible, and those improvements will be more than minimal, then you can get a LOT of procedures covered in California.
I have been involved in getting the DMHC to enforce this statute, and as of March, they are doing it. See, for example, this document regarding Health Net, in particular on pages 8 and 25-26 of the PDF:
http://dmhc.ca.gov/library/reports/med_survey/surveys/300ful l031411.pdf
See page 11-15 of the PDF regarding UHC:
http://dmhc.ca.gov/library/reports/med_survey/surveys/126fol lowup070511.pdf
Blue Shield: pages 23-24:
http://dmhc.ca.gov/library/reports/med_survey/surveys/043ful l011410.pdf
You CAN get insurance coverage for reconstructive surgery (by definition, not cosmetic) - but you have to jump through hoops. In CA, there is NO requirement for medical necessity!
First of all, your blanket statement that reconstructive surgery is cosmetic is simply WRONG. Reconstructive surgery is a subset of plastic surgery and is by definition not MERELY cosmetic.
Second, if medical necessity for a procedure can be established, e.g., for intractable intertrigo, functional impairment, etc., ANY insurance company can be forced to cover reconstructive surgery.
Third, you don't know California law.
The California Health and Safety Code 1367.63 mandates that health care service plan contracts issued or delivered in California on or after July 1, 1999 cover reconstructive surgery that is necessary to achieve the purposes specified in paragraphs (1) or (2) (note: in the alternative, not conjunctive) of subdivision (c) of that section:
1367.63. (a) Every health care service plan contract, except aspecialized health care service plan contract, that is issued,amended, renewed, or delivered in this state on or after July 1, 1999, shall cover reconstructive surgery, as defined in subdivision (c), that is necessary to achieve the purposes specified in paragraphs (1) or (2) of subdivision (c). Nothing in this section shall be construed to require a plan to provide coverage for cosmetic surgery, as defined in subdivision (d).
(b) No individual, other than a licensed physician competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for treatment pursuant to this section. For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed individual, competent to evaluate the specific clinical issues involved in the care requested.
(c) "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:
(1) To improve function.
(2) To create a normal appearance, to the extent possible.
(d) "Cosmetic surgery" means surgery that is performed to alter or reshape normal structures of the body in order to improve appearance.
(e) In interpreting the definition of reconstructive surgery, a health care service plan may utilize prior authorization and utilization review that may include, but need not be limited to, any of the following:
(1) Denial of the proposed surgery if there is another more appropriate surgical procedure that will be approved for the enrollee.
The California Health and Safety Code 1367.63 mandates that Health Net (as a provider of a health care service plan contract issued or delivered in California on or after July 1, 1999) cover reconstructive surgery that is necessary to achieve the purposes specified in paragraphs (1) or (2) (note: in the alternative, not conjunctive) of subdivision (c) of that section:
1367.63. (a) Every health care service plan contract, except aspecialized health care service plan contract, that is issued,amended, renewed, or delivered in this state on or after July 1, 1999, shall cover reconstructive surgery, as defined in subdivision (c), that is necessary to achieve the purposes specified in paragraphs (1) or (2) of subdivision (c). Nothing in this section shall be construed to require a plan to provide coverage for cosmetic surgery, as defined in subdivision (d).
(b) No individual, other than a licensed physician competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for treatment pursuant to this section. For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed individual, competent to evaluate the specific clinical issues involved in the care requested.
(c) "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:
(1) To improve function.
(2) To create a normal appearance, to the extent possible.
(d) "Cosmetic surgery" means surgery that is performed to alter or reshape normal structures of the body in order to improve appearance.
(e) In interpreting the definition of reconstructive surgery, a health care service plan may utilize prior authorization and utilization review that may include, but need not be limited to, any of the following:
(1) Denial of the proposed surgery if there is another more appropriate surgical procedure that will be approved for the enrollee.
(2) Denial of the proposed surgery or surgeries if the procedure or procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, offer only a minimal improvement in the appearance of the enrollee.
(3) Denial of payment for procedures performed without prior authorization.
(4) For services provided under the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), denial of the proposed surgery if the procedure offers only a minimal improvement in the appearance of the enrollee, as may be defined in any regulations that may be promulgated by the State Department of Health Services.
(2) Denial of the proposed surgery or surgeries if the procedure or procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, offer only a minimal improvement in the appearance of the enrollee.
(3) Denial of payment for procedures performed without prior authorization.
(4) For services provided under the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), denial of the proposed surgery if the procedure offers only a minimal improvement in the appearance of the enrollee, as may be defined in any regulations that may be promulgated by the State Department of Health Services.
~~~
Morbid obesity is a disease. Many of our post-weight loss skin laxity issues constitute abnormal structures of the body. If you can get a plastic surgeon to prepare a letter requesting authorization for these procedures, stating that in his opinion, you have abnormal structures of the body, caused by the disease of morbid obesity and the treatment for that disease, for which reconstructive surgery procedures can improve appearance to the extent possible, and those improvements will be more than minimal, then you can get a LOT of procedures covered in California.
I have been involved in getting the DMHC to enforce this statute, and as of March, they are doing it. See, for example, this document regarding Health Net, in particular on pages 8 and 25-26 of the PDF:
http://dmhc.ca.gov/library/reports/med_survey/surveys/300ful l031411.pdf
See page 11-15 of the PDF regarding UHC:
http://dmhc.ca.gov/library/reports/med_survey/surveys/126fol lowup070511.pdf
Blue Shield: pages 23-24:
http://dmhc.ca.gov/library/reports/med_survey/surveys/043ful l011410.pdf
You CAN get insurance coverage for reconstructive surgery (by definition, not cosmetic) - but you have to jump through hoops. In CA, there is NO requirement for medical necessity!
Well, excuse me. She asked for an opinion, and I was only expressiong those issued I'd actuallly heard about at 100 support group meetings. I forgot you are the expert. Dave
Dave Chambers, 6'3" tall, 365 before RNY, 185 low, 200 currently. My profile page: product reviews, tips for your journey, hi protein snacks, hi potency delicious green tea, and personal web site.
(deactivated member)
on 7/30/11 1:39 am, edited 8/1/11 8:58 am - Califreakinfornia , CA
on 7/30/11 1:39 am, edited 8/1/11 8:58 am - Califreakinfornia , CA
On July 30, 2011 at 6:49 AM Pacific Time, Dave Chambers wrote:
Well, excuse me. She asked for an opinion, and I was only expressiong those issued I'd actuallly heard about at 100 support group meetings. I forgot you are the expert. Dave
Your opinion was wrong Dave.
(deactivated member)
on 8/1/11 8:57 am - Califreakinfornia , CA
on 8/1/11 8:57 am - Califreakinfornia , CA
On August 1, 2011 at 2:25 PM Pacific Time, Cinn wrote:
Please be nice to Dave. An opinion cannot be 'wrong.' Grammar, however, can be. None of us are perfect. 
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