Insurance Coverage

Insurance coverage is getting tougher to obtain for excess skin removal after weight loss. The insurance companies have at least been more clear about their requirements, though.

These days, you are going to have to prove medical necessity. hat usually means skin that causes rashes or infections that do nor go away in spite of conservative treatment.  If you have been to the doctor for that, you have a good chance at getting coverage for the abdomen at least.

I have a page on my website dedicated to obtaining coverage that may be useful, and it includes links to some of the carrier's policies on tummy and breast approval:

http://drlomonaco.com/files/tips_on_getting_your_plastic_surgery_approved.pdf 

Dr LoMonaco, I'm just starting this process.   I've lost 150 lbs over the last 18 months (most within first 12 months).  My weight has been stable and I think I'm done losing weight.  I called my insurance to see if excess skin removal was covered and they said I'd need a doctor to submit a letter of medical necessity for them to review.   That is all the clarification they'd give me.   I then went on their website and pulled a list of providers in my area.   I've consulted with two of them - both basically made me feel like they weren't willing to jump through the insurance hoops in order to get coverage - but of course they were willing to finance me.    If I'm going to have to pay out of pocket I'll probably end up going to Mexico (that's where I had my VSG).   But I'd really prefer to have plastics done in the US if I can get insurance to cover it.   I'm willing to travel inside the US if I find a physician that is able to get it covered and is willing to "bother" with the insurance company.    How do I go about finding a plastic surgeon who is willing to do this without wasting a lot of my time and their time?   This last one I specifically asked if they were willing to work with insurance before I set up my consult - but when I arrived he basically said he wouldn't submit to insurance unless I'd been hospitalized for skin infections or open sores.  

I'd appreciate any help you can provide as far as the best way to approach this.   I thought I was approaching it correctly (calling insurance, using preferred local providers) but so far that isn't working.

Thanks,

Jane

Hi Jane. Sorry for your issues. The reasons doctors are hesitant is because INS pays for just skin removal...not the fine work and detailed care and extra work that give a good result. Insurance usually pays half or less that the standard and customary fee for a TT. The other issue is they often do not cover other needed areas (arms, legs, pubic roll, buttocks) at all.

You should be able to sort out on the phone to see if an office is willing to cooperate.

Check my website article...the letter of med necessity is not too bad of a "flaming hoop" if your "ducks are in a row."  What is your insurance company ?  Likely they want 3 months of excess skin treatment (not necessarily hospitalization) to declare your skin removal  "medically necessary." 

It's BCBS PPO plan.   I understand that insurance will only cover for skin removal...but I was hoping what they did cover would then allow me to pay out of pocket for the rest without it being the full burden of cost on me.   If I can find a way to bring the cost of plastics down to something comparable to having surgery out of country then I'd really prefer to have it here.   I'd even be willing to pay a little more to have it here.   Just not able to afford $25k which is what the first surgeon quoted for lower body lift, arms, inner thigh lift, and breast lift (without implants).  

Here are links to the Anthem "Blue" plans from my website

ANTHEM –Blue Cross Abdominoplasty

http://www.anthem.com/ca/medicalpolicies/policies/mp_pw_a053328.htm

Breast Procedures

http://www.anthem.com/ca/medicalpolicies/policies/mp_pw_a050277.htm

Excess Skin of Other Areas

https://www.bcbsal.org/providers/policies/final/058.pdf

You can see they are pretty clear about what they need to provide coverage. I am saddened to see they do not see the medical benefit of excess inner thigh skin, which causes rash, irritation, and infection too.  

Remember your surgeon fee may only be partially covered and he may charge you out of pocket for uncovered services.  But your hospital and anesthesia may be covered more liberally, thus reducing your overall costs.

As for costs, yes, 15k and up is about right for a lower body lift and it's about $3-4k for everything after that you add.  CareCredit can help some people finance, and there are other financing companies too. Cant say I like their interest rates though.  

I am against out-of-the-country surgery simply because I receive calls and emails form patients who have had issues, some severe.  You have no legal protection, probably no insurance coverage if you need extra care, and implants placed out of the U.S. (even if they are made in the U.S.) are NOT warrantied. The warranty includes complete payment (surgeon, hospital, anesthesia) for rupture, coverage for capsular contracture in the case of Mentor implants, and lifetime implant replacement. Its a very valuable warranty, and there is a disturbing reason neither Mentor or Allergan honor warrantiesfor implants placed elsewhere.  

I am still concerned that there is no online resource (please correct me if I am wrong and anybody finds one) where a patient can check the lawsuit, complaint, or compliance history of their doctor OR hospital in Mexico.  Joint Commission International, an organization dedicated to patient safety, certifies 3 facilities in Mexico.  In contrast, ALL hospitals in the U.S. must meet their rigorous standards.   Why no certification of more facilities in Mexico ?  Because it costs extra pesos to meet their safety standards. Once again,  there is a reason it is much cheaper down there.

Thank you for the detailed pdf explaining this in more depth.

So if we were lucky enough then to get our insurance company to cover the skin removal only, what portion of the procedure cost would they cover if we were to opt pay out of pocket for the more aesthetically pleasing result?  Say we want a LBL, would  the skin removal be say 20% or $2000 or some other small fractional amount of the total cost?

That I do not know, because if your provider is contracted with BCBS, he gets a set amount for a tummy tuck. Anything he does beyond that he may bill you for and you will have to negotiate this.  Same thing with hospital and anesthesia.  

I don't mean an actual exact amount, I meant what would be a ballpark amount of a lower body lift would they typically cover.  Is it just a fraction or closer to half, something along that line.  I am just trying to get a rough guesstimate of what to expect.

I am out of network, and I have been paid anywhere from 10 to 40% of my fee. 3 times in the past few years, I have been given approval, in writing. and then not paid at all. They said they made a mistake. Then they withold payment on my other patients till we are square  The companies are very tight-lipped about disclosing what they pay and I know it varies. It has to be one of the dumbest, most complicated systems ever devised. Sorry, but I cant be any more specific than that.

No, that is what I was wondering about.  So if a procedure cost say $10k or more, they could easily end up just paying $1k-4k and we would still be having to pay the rest out of pocket.  I was wondering if it was worth the time, effort and potential frustration.  Thank you very much for taking the time to answer!