Hi All,

    I am almost one year post op from Gastric Bypass. I have lost 120 pounds. I am very comfortable at the weight I am at. My original goal was 6 more pounds, however my extra skin weighs more then that 6 pounds. I would be under goal without the extra skin.

I could live with the extra skin BUT..... my problem is I had 4 prior surgeries on my stomach. I had 2 c-sections, a emergency surgery due to a cyst bursting, and a hysterectomy. I was cut up and down for 3 of the surgeries and had a bikini cut for one of the c -sections. With all the extra skin I am having troubles with the fold of skin going over my previous scarred area and over my very deep innie of a belly button.  No air gets to these areas and when I take of my clothes at the end of the day I have sweaty, smelly, itchy, and sore areas along these previous surgery scars and my belly button. I have tried powders, my surgeon told me to use desitin (not only does that make me stink, it doesnt seem to be working). I shower daily and I make sure that I dry the areas really well and I still seem to have issues at least once every other week. I have very long days. I leave my house around 7:30am  and I do not arrive back home until sometimes 10:30-11 pm. All this time I am confined in clothes. I try to sleep without clothes so that the air can get to these areas but we all know after weight loss surgery we are all freeeeeeeeeeezing all the time and with it being winter I just cant sleep with no clothes on.

How do I get my insurance to agree to paying for a tummy tuck to take care of these issues? Where do I start? and is only being post op for 11 months long enough to start this journey?
Any help is greatly appreciated.

ps.... I have BC/BS insurance

Just have your PCP document all your issues and BCBS should approve at least a Panni.  Go to a PS and I'm sure they will help you submit the proper paperwork to insurance.

Start with a consult with a PS that does weight loss patients. I got referals from my bariatric center. I also have BCBS (althought the have lots of different plans). I never had a rash and was approved for a panniculectomy without a problem. That removes the extra skin below the belly button. I 'upgraded' to all the extra abdominal skin with my BB getting moved (no muscle tightening). Some like you to have maintained your weight for a certain amount of time.

Good luck!!
Martha

Hi, I had a panniculectomy three weeks ago and it was all paid by insurance. Typically if there is a documented medical reason for having one the insurance will pay for it. In my case they needed the following:

For me to be at goal weight and maintaining for 18 months or more

For me to have a medical reason for needing the procedure, in your case you have skin issues which need to be documented over a period of time by your doctor, as part of the process to get approval for the surgery, your plastic surgeon will need to submit evidence of your medical issues, in my case there was a third criteria which was the size of the pannus(or skin hanging over your pubic area)

The following is a section cut and pasted from an insurance company that states the cir****tances under which they would consider the surgery, review the policy with your particular insurance company, they should be able to provide you with this information and then start the documentation process,  good luck

Guidelines for Medical Necessity Determination for Panniculectomy

---

These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine medical necessity for panniculectomy. A panniculectomy is a surgical procedure to remove the panniculus or excess skin and fat that forms an apron. It does not include tightening of the abdominal muscles (abdominoplasty). These Guidelines address only panniculectomy and are based on generally accepted standards of practice, review of the medical literature, and federal and state policies and laws applicable to Medicaid programs.

Providers should consult MassHealth regulations at 130 CMR 433.000 and 450.000 and Subchapter 6 of the Physician Manual for information about coverage, limitations, service conditions, and other prior-authorization requirements.  Providers serving members enrolled in a MassHealth-contracted managed care organization (MCO) should refer to the MCO’s medical policies for covered services.

MassHealth reviews requests for prior authorization on the basis of medical necessity. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including member eligibility, other insurance, and program restrictions.

Section I. General Information

Panniculectomy is the removal of excessive skin, subcutaneous tissue, and fat of the abdomen. MassHealth considers approval for coverage of panniculectomy on an individual, case-by-case basis, in accordance with 130 CMR 450.204.

Section II. Clinical Criteria

A. Clinical Coverage

MassHealth bases its determination of medical necessity for panniculectomy on a combination of clinical data and the presence of indicators that would affect the relative risks and benefits of the procedure (if appropriate, including post-operative recovery). These criteria generally include, but are not limited to, the following:

1. The member is 18 years of age or older.
2. The member has had substantial weight loss, stable for at least six months.
3. The panniculus causes a chronic and persistent skin condition, for example, intertrigo, cellulitis, or tissue necrosis, that has not responded to   six months or more of conventional treatment.
4. The panniculus hangs to or below the level of the symphis pubis.
5. The panniculus either:
   1. significantly interferes with mobility or activities of daily living (ADL); or
   2. contributes substantially to a recurrent or extensive incisional hernia or ventral hernia.
6. A comprehensive medical history, surgical history, and physical exam have been conducted to identify functional impairment, including:
   1. the member’s age and current height and weight;
   2. medication list;
   3. documented history of clinical symptoms pertinent to the diagnosis, including any
   4. interference with mobility or activities of daily living (ADL);
   5. previous and current use of prescribed or over-the-counter remedies related to dermatologic
   6. complications of the panniculus;
   7. current medical conditions, risk factors, and comorbid conditions; and
   8. previous surgeries or hospitalizations.
7. The panniculectomy may occur simultaneously with surgery for biopsy-proven cancer to optimize surgical field exposure.

B. Noncoverage

MassHealth does not consider panniculectomy to be medically necessary under certain cir****tances. Examples of such cir****tances include, but are not limited to, the following:

1. The member has difficulty in fitting clothes.
2. The panniculectomy is to be performed at the same time of gastric bypass; and
3. The procedure is for cosmetic purposes.

Section III. Submitting Clinical Documentation

Requests for prior authorization for panniculectomy must be accompanied by clinical documentation that supports the medical necessity for this procedure.
 

1. Documentation of medical necessity must include all of the following:
   1. the primary diagnosis name and ICD-9–CM code pertinent to the clinical symptoms;
   2. the secondary diagnosis name and ICD-9-CM code pertinent to comorbid condition(s);
   3. a summary of the medical and surgical history, including the member’s weight-loss history;
   4. documentation of the last physical exam, including the information specified in Section II.A.6;
   5. documentation of recurrent intertrigo, cellulitis, or skin necrosis that has failed to respond to medical management for six  months or more;
   6. documentation of ADL restrictions related to the panniculus;
   7. photographic documentation, frontal and lateral views, of the panniculus, taken within the last six months; and
   8. other clinical information that MassHealth may request.
2. Clinical information must be submitted by the surgeon involved in the member’s care. Providers must submit all information pertinent to the diagnosis using the Automated Prior Authorization System (APAS) at www.masshealth-apas.com or by completing a MassHealth Prior Authorization Request form and attaching pertinent documentation.

Select References

Acarturk TO, Wachtman G, Heil B, Landecker A, Courcoulas AP, Manders EK. Panniculectomy as an Adjuvant to Bariatric Surgery. Annals of Plastic Surgery. 2004;53,4:360-367

Bariatric Surgery. Info Panniculectomy Surgery page. Panniculectomy After Weight Reduction page. Available at: http://bariatric-surgery.info/. Accessed January 24, 2006.

Igwe Jr D, Stanczyk M, Lee H, Felahy B, Tambi J, Fobi M. Panniculectomy Adjuvant to Obesity Surgery. Obesity Surgery, 2000;10:530-539.

Reid, RR, Dumanian GA, Panniculectomy and the Separation-of-Parts Hernia Repair: A Solution for the Large Infraumbilical Hernia in the Obese Patient. Plastic and Reconstructive Surgery. 2004;116,4:1006-1012.

Savage RC. Abdominoplasty

Thank you all for the information. I have taken pictures which are dated. I also have mention this issue with my primary Dr and my surgeon so I am sure it is documented in my files.  Well after the holidays I will start this next step of my journey. I will talk to my sergeon and primary, get PS referrals and then make an appointment with a PS.

HAPPY HOLIDAYS!

Good luck with everything! I'm only 9 months out and insurance has approved me for a LBL/TT, i too have BCBS of TX.

In the mean time, what I've found that helps me the most with my irritated skin is washing with Hibiclense when I shower (just the affected areas, that stuff dries you out) and then following up with Lamisil athlete's food powder, I know it sounds weird but I did alot of research on Candidia and that's what I think causes the itchy, smelly rash. Candidia is a yeast that we all have in our bodies and it's considered a fungus, so the Lamisil powder is designed to kill athlete's foot which is also a fungus....so it really makes sense...it also works! I'm pretty sure you can get Hibiclense at the drugstore or online, your surgeon may have some, that's where I got mine.

Again good luck and keep us posted on your progress!!