Plastic Surgery-how to get the insurance company to pay?!

Hi ya'll!

I'm a success story- been 8 years since my WLS. Now I'd like to finish the job, with a tummy tuck- not a huge one, but enough that I'd like to take that final step. I consulted with a surgeon, but was promptly rejected by my insurance company- they said it was cosmetic.

What do I hafta do to get them to pay??

Nothing; it's cosmetic.

You might get them to cover a very small portion for the paniculectomy portion, but it's not much.  You're going to need to save up.  Insurance will not cover cosmetic procedures, period.

Hi

 

Check out an article I wrote a while back about the insurance process.

http://drlomonaco.com/houston/patient-resources/

The page is acting funny so be sure you

RIGHT CLICK ‘SAVE AS’ TO DOWNLOAD ARTICLE

 

It's in PDF format.

Best,

Dr LoMonaco

check out the insurance guidelines for covering reconstructive surgery, see if your policy even covers it and go from there....

Can I ask what insurance company you have? 

Guess what - today, I finally got approved for abdominoplasty surgery.  I was denied last year, they said it was cosmetic.  My insurance is Anthem - Blue Cross Blue Shield.  While just playing on the internet later last year, I found a clause in their own insurance plan which basically said that sometimes it is medically necessary.  I had statements from two physicians saying it was medically necessary. 

Here is what I found in Anthem's medical policy:

 

Description/Scope

This document addresses the surgical procedures panniculectomy and abdominoplasty and when they are considered medically necessary, not medically necessary and cosmetic.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment. 

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

 

Position Statement

Medically Necessary:

Panniculectomy is considered medically necessary for the individual who meets the following criteria:

1. The panniculus hangs below the level of the pubis (which is documented in photographs); AND
2. One of the following:
   • there are documented recurrent or chronic rashes, infections, cellulitis, or non-healing ulcers, that do not respond to conventional treatment for a period of 3 months; OR
   • there is documented difficulty with ambulation and interference with the activities of daily living;
     AND
3. Symptoms or functional impairment persists despite significant* weight loss which has been stable for at least 3 months or well-documented attempts at weight loss (medically supervised diet or bariatric surgery) have been unsuccessful; AND
4. If the individual has had bariatric surgery, he/she is at least 18 months post operative or has documented stable weight for at least 3 months.
   
   *Significant weight loss varies based on the individual clinical cir****tances and may be documented when the individual:
   1. Reaches a body mass index (BMI) less than or equal to 30 kg/m^2_; OR
   2. Has documented at least a 100 pound weight loss; OR
   3. Has achieved a weight loss which is 40% or greater of the excess body weight that was present prior to the individual's weight loss program or surgical intervention.

Panniculectomy is considered medically necessary as an adjunct to a medically necessary surgery when needed for exposure in extraordinary cir****tances.

Not Medically Necessary:

Panniculectomy is considered not medically necessary when the criteria above are not met.

Panniculectomy is considered not medically necessary as an adjunct to other medically necessary procedures, including, but not limited to, hysterectomy, or incisional or ventral hernia repair unless the criteria above are met.

Panniculectomy or abdominoplasty, with or without diastasis recti repair, for the treatment of back pain is considered not medically necessary.

Cosmetic and Not Medically Necessary:

Liposuction is considered cosmetic and not medically necessary for all indications. 

Abdominoplasty when done to remove excess skin or fat with or without tightening of the underlying muscles is considered cosmetic and not medically necessary.

Repair of diastasis recti is considered cosmetic and not medically necessary for all indications.

_______________________________________________________________________________________

So after finding this, I knew that I met these qualifications, so I thought it would be no problem.  I had my plastic surgeon resubmit my information.  Guess what?  Denied again - again said it was cosmetic.  This time, I called the lady who was in charge of the denial and asked her why.  In her fluffy brained way, she said they just automatically denied all of them without even considering them and called them all cosmetic.  She suggested that I appeal it and write in my own words why I thought I needed to have the surgery.  You have to understand that this is a $10,000 surgery (what my surgeon quoted me) so it was very important to me, so I stressed out for months over this letter.  I mean literally I stressed out for 5 months over this letter.  I wrote it and re-wrote it so many times it was ridiculous.  Finally, I just sent the damn thing in right after Thansksgiving weekend.  Of course, there was a week delay because they misplaced my paperwork.  Then come to find out, when I had spent 5 months stressing over writing the damned letter, that was a waste of energy.  All I needed to do was write one sentences saying "I suffer from constant infections and rashes that make it difficult to complete my job and interfere with my day to day living."  This would have triggered the appeal to go in front of the medical review, because then it was approved. 

So that is why I am asking what company you are insured with.  I am hearing now that there are a lot more companies that are covering it.  Why?  I have even heard that Medicare will cover panniculectomy if medically necessary. 

Robin Widner

Thank you! Thank you so much for this. 

I have discomfort and swelling when working out. Stomach problems so bad that I had a scope shoved down my throat. Trying to figure out why the hell my stomach would well and have discomfort.  I also have back pain when picking things up and it causes so much pain I've nearly dropped my son. 

I can't work out without swelling and pain.

I can eat with our feel some sort of discomfort. 

I have a belly that drops to my pelvic line. ) not that i care about that as much. 

I just got diagnosed with this and cried for hours because I know I don't have 10,000$ to get it done. 

So you. You have given me some hope. Some sort of reason today to stop crying. I will fight thanks to you. 

So when you say abdimoplasty you mean they approved for the muscle repair to be done as well? Not just a panni? Removal of the flap?