PS and Insurance

This is a cross-post from the PS board, but want to get input from others also. If you can offer insight I'd appreciate it. Original Post: Hello, this is my first post on the PS board. I'm ready to begin the process of trying to get insurance approval. In reading my policy here are a couple of things I've noted. If anyone can offer help/info/suggestions, I'd greatly appreciate it. Reconstructive Procedure: Services for reconstructive procedures, when a physical impairment exists and the primary purpose of the procedure it to improve and restore physiologic function. Reconstructive procedures include surgery or other procedures which are associated with injury, sickness or contential anomoly. The fact that physical appearance may cange or improve as a result of a reconstructive procedure does not classify such surgery as a cosmetic procedure when a physical impairment exists, and the surgery restores or improves function. Cosmetic procedures are exclused from coverage. Procedures that correct an anatomical congenital anomoly without improved or restoring physiologic function are considered cosmetic procedures. The fact that a covered person may suffer psychological consequences or socially avoidant behavior as a result of an injury, sickness or contenital anomaly does not classify surgery or other procedures done to relieve such consequences or behavoir as a reconstructive procedure. In the definition of sickness it states: physical illness, disease or pregnancy. The term sickness as used in this certificate does not include mental illness or substance abuse. Sorry this is so long, I'm really hoping to get some help from insurance on PS since I've paid a bundle as a self-pay for my RNY, although I'm not complaining it's the best money I've ever spent. So do you think it's a possiblity to get insurance to pay for a TT? Thanks, Dana

By the looks of your pix you look great, GOOd job!!! Unfortunatly by the looks of your body I doubt insurance will pay for anything...you look that good. for a tt you must have a pannus that hangs below the mons pubus area, rashes under it and it must cause functional and mobility problems, loose skin doesnt qualify, sorry, Same as for breast lifts, , long pendulous breast, rashes, back pain...anything is worth try, If you self pay and do it as out pt, it should be only 5000 to 8000, total cost. Good luck plastic surgery is well worth the money, my ins paid for tt-panulectomy, breast reduction-52FFF to a perfect perky 38C.

Hi there, beautiful! What a gorgeous smile on your new pic! I have to agree with Rosemary, chances are you aren't going to get covered. My insurance (Aetna) had similar language but included a paragraph about what constituted a medical necessity for a TT and it was pretty stringent. I didn't have a chance. I had a TT and BA and self-paid. Consider having dual procedures with 2 surgeons at once. Procedures have a set cost but you'll save $$ through less operating room time and anesthesioligist time. Plus, they'll often cut you a rate discount doing it that way. All said and done, including aftercare, my TT and BA cost about 10K. Good luck, Sweety!

Hey Dana! I have pretty much the same language in my insurance and they are not going to cover. I spent time and a lot of effort to see if I could get it done and they would not approve me. I am going self paid..... it is breaking my piggy bank but in the long run I think it will be worth it! Hope things work out better for you!! Valerie

Dana - I have Aetna, and pretty much they won't pay for a TT because it is considered cosmetic surgery. You might be able to try for a panniculus removal (skin removal from the tummy area), only draw back is the doctor won't tighten you stomache muscles,which give the appearance of a flatter stomache. But the only way Aetna will pay for this procedure is if you can document that you have medical problems, i.e., rashes and convential treatment doesn't work for you. I ended up self paying, doing several procedures at once, to save money. Donna open rny mar 18 2003 282/143/140

Dana, I totally disagree with the other replies. This is not cosmetic it is reconstruction due to a surgery procedure. Talk to your bariatris surgeon to see who he recommends that is in your network if need be. PS who work with bariatric patients know it is medically necessary. They will ask you if you have rashes in that area, I said yes when I was "prompted". He asked if the extra skin and mine was minimal honest was "still bothering me and still giving me those backaches", and again I said yes. So he sent it in as med necessary and of course the decision was up to my ins. co and they did approve me for TT and butt lift. As you know my breast lift was done with a reduction and well. He took the pictires from an angle that showed I needed a reduction and actually there was not really enough cc's to reduce my breast size,, he used that tissue for the lift and I am still the same size cup size as before...I trusted he knew what he was doing and again he asked "if my back and shoulders were still hurting and was a getting rashes still under my breast" and again I was be prompted to say the right answers, they can't ethically write that up unless it comes from "youir mouth." Today I saw him and he is sending in a request for thigh lift and again asked "if I am still getting rashes when my thighs rub together" of course I said yes, pictures were taken and I should have an answer in a weeik or two since they are backed up with paperwork due to holidays. He also is putting in for a revision for above belly button which is protuding over naval and my left hip has a little bulge which didn't go away after healing from TT. I am not sure I want the thigh scars, after he explained he wouls have to do inner thigh long scar and when he pulled up the skin he would have to attach it to bone in groin area and if that doesn't hold can cause problems with labia felling like air going up there constantly I am really concerned since I had a dropped bladder for 36 yrs which he repaired with TT so not sure what my decision will be even if approved. So I say find thr right man or women who work with bariatric patients that are in your network first. Let them file for approval first before you even think about having to pay. I never thought my ins would pay and they "do not pay for any cosmetic surgery". In these case after bariatric it is considered reconstuctive and you might be surprised that they may approve it...give it a shot, nothing to loose except the excess skin and gain huge self confidence. You are young and I know this is a burden, I am much older and thought they would deny me but I have been blessed, please try to get approved...its expensive and I know I couldn't have paid 22,000 plus hospital fee amd anesthia. All my surgeries cost me was copays which totaled 125. Your ins does sound like reconstruction surgey is covered from what I comprehened but they so have loopholes and right dr will know how to write it up for possible approval. Try to find someone in a teaching hosptal, preferrably head of the dept if he is in network. FYI I never had any rashes. Hugs and good luck, Ginny