Aetna POS II and Plastic Surgery

Ok, I am now at the point where I am looking forward to having a little nip and tuck here and there. because of the rapid weight loss by boobies are going south and so is my stomach. I don't want a tummy tuck as of yet because I have not had children yet, however, I would like lippo and breast lift and reduction. Does anyone have Aetna Insurance and what is their stance on approving and paying for these types of surgery. Please help!!

Like anything else it depends on your individual coverage. Usually it has to be medically necessary.

The Aetna plan that I had (also a POS II, and although the plan is slightly different for different employers, they are pretty uniform on cosmetic surgery).  They only cover plastic surgery that is medically necessary.  They will only cover a panniculectomy (removal of excess skin below the navel), and  will only cover that fi you can show documentation of a certain number of montsh of skin rashes that did not respond to treatment with prescription creams/powders AND it hangs below the pubic bone.  They will not pay for a breast lift under any cir****tances and the only way they will pay for a breast reduction (without a lift) is if you have 500g of tissue to be removed from EACH breast (which is at least a DD cup!) and can show that you have at least two medical issues that are a direct result of the weight of your breasts.

They covered my panniculectomy with no hassle, but they would not cover the mons lift and even though I also had horrible rashes in my armpits (with pictures and medical documentation) because of the huge batwings that I had after losing the weight, they absolutely refused to cover any portion of the arm lift.

No insurance company is going to pay for liposuction.

Lora

Yes I am a DDD Cup now and Iam hanging terribily, I wear poweder everyday as a religion, and used to get rashes under the boobs and between. Also what is a panniculectomy? Is that a tummy tuck?

No, a panniculectomy is not a tummy tuck. It is the removal of just the excess skin that hangs on your lower abdomen (from your navel downward). There is no muscle tightening involved and it does not do anything about excess skin ABOVE the navel (so sometimes people with just a  panniculectomy still need a tummy tuck to get rid of the "muffin top" effect from the excess skin at (and above) the waist.

Unfortunately, rashes under your breasts are usually not considered a medical reason for a breast reduction. Below is the clincial bulletin (policy) from Atena on breast reduction  (as you can see, you have to have a number of significant, documented problems for over a year in order to get a reduction covered):

Lora

Reduction Mammoplasty:

Aetna considers breast reduction surgery cosmetic unless breast hypertrophy is causing significant pain, paresthesias, or ulceration (see selection criteria below). Reduction mammoplasty for asymptomatic members is considered cosmetic.

Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete when the following criteria is met:

1. Macromastia: all of the following criteria must be met:

   1. Member has persistent symptoms in at least two of the anatomical body areas below, affecting daily activities for at least one year:

      • Headaches
      • Pain in neck
      • Pain in shoulders
      • Pain in upper back
      • Painful kyphosis documented by X-rays

      • Pain/discomfort/ulceration from bra straps cutting into shoulders;

      and

   2. All of the following criteria are met:

      1. Photographic documentation confirms severe breast hypertrophy; and

      2. Member has undergone an evaluation by a physician who has determined that all of the following criteria are met:

         1. There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; and
         2. Reduction mammoplasty is likely to result in improvement of the chronic pain; and

         3. Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as:

            • Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions
            • Physical therapy/exercises/posturing maneuvers
            • Supportive devices (e.g., proper bra support, wide bra straps);

         and

      3. Women 40 years of age or older are required to have a mammogram that was negative for cancer performed within the year prior to the date of the planned reduction mammoplasty;

      and

   3. The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area:

      Table: Weight of breast tissue removed, per breast, as a function of body surface area

      Body Surface Area (m2)

      Weight of tissue removed per breast (grams)

      1.40 1.41 1.42 1.43 1.44 1.45 1.46 1.47 1.48 1.49 1.50 1.51 1.52 1.53 1.54 1.55 1.56 1.57 1.58 1.59 1.60 1.61 1.62 1.63 1.64 1.65 1.66 1.67 1.68 1.69 1.70 1.71 1.72 1.73 1.74 1.75 1.76 1.77 1.78 1.79 1.80 1.81 1.82 1.83 1.84 1.85 1.86 1.87 1.88 1.89 1.90 1.91 1.92 1.93 1.94 1.95 1.96 1.97 1.98 1.99 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20

      324.3 330 335 340 350 355 360 365 375 380 385 395 400 405 415 420 430 435 445 455 460 470 480 485 495 505 510 520 530 540 550 560 570 580 590 600 610 620 635 645 655 665 680 690 705 715 730 740 755 770 780 795 810 825 840 855 870 885 900 915 935 950 965 985 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000

      To calculate body surface area (BSA) see http://www-users.med.cornell.edu/~spon/picu/calc/bsacalc.htm

      OR
      
      BSA (m2 ) = ([height (in) x weight (lb)]/3131)½

      BSA (m2 ) = ([height (cm) x weight (kg)]/3600)^½

   Note: Breast reduction surgery will be considered medically necessary for women meeting the symptomatic criteria specified above, regardless of BSA, with more than 1 kg of breast tissue to be removed per breast.

   Note: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold in and of themselves are not considered medically necessary indications for reduction mammoplasty. The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of six months or longer, but also must satisfy criteria stated in I above.

i agree w/****ro. you need be get lot's of documentation. i used aetna but had to make many office visits and document pain, rashes, soars, etc. and one appeal before i got approval. but it was well worth it.