Post Bariatric Plastic Surgery And Insurance Coverage
by Dr. Steven Gitt and Dr. Dominic Heffel
After weight loss surgery, the patient’s body will typically shed excess pounds very quickly, but there can be up to a two year wait between your surgery and reaching your target goal weight. At the two-year anniversary, most successful weight loss patients have lost 100 pounds or more of body weight. The more successful and dramatic the weight loss is, however, the more excess skin can be left behind after weight loss goals are met. Almost all patients who experience sagging skin at the end of the weight loss journey have baggy skin in the abdomen area. This is the primary area that our patients request plastic surgery to correct. After the abdomen, the breasts, arms, thighs and buttocks are areas that tend to have drooping skin after your drastic weight loss. Plastic surgeons can remove extra skin, tighten and contour a patient’s skin to their newly slender body.
Many people want to know if their health insurance will cover the cost of their plastic surgery procedures. The answer is that some procedures are covered, while others are not covered. Each insurance policy has differing criteria for coverage, so this article will address issues with insurance as a guideline for our patients to check with their plastic surgeon and their insurance company to confirm coverage.
Insurance will cover the cost of some procedures if they are considered reconstructive in nature. (Reconstructive surgery is defined as: Surgery undertaken to restore normal structure or function). Moreover, the surgical correction of any cosmetic defect that significantly impacts function of the body part in question may also be covered. (Cosmetic Surgery is defined as: Surgery undertaken to enhance an otherwise normal structure or function to a “Super-Normal” status). Basically, reconstructive surgery is considered surgery that addresses health concerns as opposed to surgery designed to make you look better.
Just to complicate things further, there also may be partial coverage available for any portion of an operation that is not considered cosmetic. In short, if the purpose of your surgery is intended only to improve your appearance, it is almost certainly not a covered expense. If, on the other hand, the procedure will correct or improve a legitimate medical concern, it may be covered in part or in full.
For post bariatric patients, hernias are covered by insurance, as is a panniculectomy, which is the removal of excess abdominal skin that can be plagued with rashes, lesions and infection. We must submit proof that these sores and rashes have been present for at least six months and that they have failed to heal despite appropriate non-surgical treatment. If these problems are present in other areas, such as the inner thighs, breasts, or under the arms, insurance will likely cover the surgery or repair of the damage. Breast reductions are sometimes covered as well, depending on the complete patient profile and symptoms. The single most helpful thing that a patient can do is to ensure that their complaints of skin sores and irritation due to the skin rubbing together, and their treatments, are well documented by their primary care physician. These medical records will provide great support towards getting your surgery covered by your insurance company.
In cases where one of our patients wants to have a tummy tuck or a body lift done at the same time as an insurance covered panniculectomy, we will make appropriate discounts on the global fee at the time that surgery is scheduled. This is because the panniculectomy procedure is encompassed within the tummy tuck procedure. So, that way, we are not charging both you and your insurance carrier for the same part of your procedure.
As each patient is unique and insurance coverage varies widely, this is only a guideline to check with your insurance company and your surgeon about possible coverage. Only they can tell you if your planned procedure qualifies for full or partial coverage by your insurance plan. Also keep in mind that your plan may include special co-pays or deductibles that apply specifically to these types of procedures. It is important to note that even when coverage is provided for reconstructive procedures, there is usually some sort of pre-certification or pre-determination required, so be sure to work with your doctor in addressing your insurance company’s coverage criteria.
In assessing whether the procedure will be covered by the patient’s insurance contract, the carrier looks at the primary reason the procedure is being performed: Is it for relief of symptoms or for cosmetic improvement? If a procedure is within these “gray areas,” insurance companies often require prior authorization or approval before the surgery is performed and/or extra documentation after surgery to determine how much of the cost of your care they will cover. Don’t miss out on having your surgery covered by failing to meet their often rigid requirements for pre-authorization or approval.
Once your surgery is scheduled, just relax and rest assured that after this last surgery, your body will be that place where you always wanted to live.
Dr. Steven Gitt and Dr. Dominic Heffel have devoted their plastic surgery practices to the care and management of post-bariatric/massive weight loss patients for more than a decade. Dr. Heffel was a UCLA bariatric surgeon before entering his residency training program in plastic surgery. For more information, go to www.nvpsaz.com, the official website of North Valley Plastic Surgery. Visit their OH Profiles at:www.obesityhelp.com/profiles/plastic-surgeon/dr-steven-gitt/ and
www.obesityhelp.com/profiles/plastic-surgeon/dr-dominic-heffel/
Click here for the PDF version of this article from its appearance in OH Magazine
Click here for the PDF version of this article from its appearance in OH Magazine
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