Insurance coverage for TT? (Long Island/NY Area)

Hi all.. im 3 years out ( on feb 1) from RNY & have been maintaining my weight since about 18 months out... so here I am ready to "finish" the appearance part of this journey. I want a TT. I've been told my some that it can be covered, and no way by other post ops.

So, have any of you had success getting this covered by insurance in the NYC/Long Island areas? What Dr (name/town)? How long was the process to get the approval? Did you need other medical documentation ( like rashes under the loose skin)? I just got new insurance- its Emblem Health (part of GHI).

The PS I most recently had a consult with said they have never gotten approval for a TT, as he is a "cosmetic surgeon" and they basically don't even bother trying to put it thru insurance.

Any help would be greatly appreciated!

I got an approval for a pannilectomy from my insurance company and I am upgrading to the full TT. The panni was considered medically necessary due to rashes and infections under my panni. It is considered reconstructive surgery not plastic surgery. My insurance is BCBS Personal Choice. For the surgery to be considered medically necessary I had to have lost at least 100 pounds, have a pannis that hung to the mons area, stable weight, and 6 months of doctor documented rashes with pictures.

Hope this helps......by the way I would call your insurance company to see what the criteria is for reconstructive surgery is after massive weight loss. If they say it is covered if the requirements are met I would find a new surgeon that will deal with your insurance........mine surgeon has been more than happy to help me get covered.

Kathy

Actually, I think you can do this!  I found a link that actually spells out what Emblem Health requires, now you need to make sure that you have all your ducks in a row and can provide all of the documentation and doctor's appointments can be verified, etc. so that when the doctor submits it for approval, it will be approved.  Here is the link:

http://www.emblemhealth.com/pdf/med_guidelines/surgical/MG_A bdominoplasty-Panniculectomy_c.pdf

But I should warn you, they do not actually spell out how low your panni has to hang.  My insurance company did.  Basically, they aren't going to pay for it unless it really hangs down pretty far. 

And here is something else important to know.  The first time mine was submitted, it was denied, and I was crushed, so I waited a year before I sent it in again. So a year later, the doctor sent it in again and again it was denied, even though I clearly met every one of the requirements listed on my insurance company's guidelines.  So I called her up and demanded to know why I was denied, and she said that they ALWAYS deny them and say the are for cosmetic reasons.  As I'm sure your insurance will too, because I did find another document from Emblem Health that I did not include the link here, which basically said they consider panniculectomy cosmetic unless it is extreme cases (like ours in extreme weight loss).  So just go in expecting to be denied, and know that you will have to do the appeal.  But when you do the appeal, it has to go to a medical board for review and then you will get the approval. 

What I would suggest, is that now that you know what you need, you make sure that you have either your three months of consecutive documented rashes or whatever thing you are going to use documented by your normal physician, who can write a letter documenting it, and the letter can also say that in their opinion the surgery is "Medically Necessary".  That is the essential wording, that it is not cosmetic, it is "medically necessary".  Then your physician can give you a copy of the letter and send a copy to your plastic surgeon.

As far as finding a plastic surgeon, I would shop around until you find one that will work with you to file the paperwork.  Yes, his office girls have to do the work but so what?   All he needs to do is take the photographs to document the rashes and how low your panni hangs so that can be sent in for their approval.  And consultations are free and if you live in NY, there should be lots of Plastic Surgeons around, I would look here on this board where you should find some that specialize in after weight loss surgery. 

Good luck, If you have more questions, you can friend me and I'll try to answer them

Robin

I have Emblem Health (used to be HIP) My TT?Panni removal was covered in full. I also had a hernia repair at the same time. Yeas, having documentation of rashes are a plus.My panni looked like an apron. If it is seen as medically necessary they should cover it, providing your insurance plan does cover it. I would give Emblem a call and see if you have the coverage.  Go online and check to see what plastic surgeons are enrolled the program. I had a consult with a women Dr in Syosett, (can't remember the name) but had my surgery done by Dr Spector at NY Presbyterian Hospital-Weill Cornell Medical Center in NYC. He did an excellent job and the hospital is fantastic. If I every need surgery in the future I would definitely go back there.