Question:
Will insurance cover an abdominoplasty if you don't have a rash?

I have Aetna HMO. I had no problem getting my revision covered due to a leak. I'm looking into getting a tt soon and wonder if anyone with this insurance can tell me if they got their surgery covered. Also, what if you have a panni, but no rash or anything underneath it? Also, has anyone ever had a breast lift covered and how? Thanks    — Michele :. (posted on April 24, 2002)

April 24, 2002
Michelle, I had an abdominoplasty done after four c-sections. I had to pay out of pocket, but it is my understanding that if you have a DOCUMENTED MEDICAL HISTORY of chronic back pain/problems, insurance MAY cover the procedure. If you call your insurance company they may be able to tell you under what conditions they would consider covering the procedure. Then again, they may say under NO circumstance. Good luck. I hope you get approval! Wish me luck too..I had my first consult 04/23 and am hoping to have WLS scheduled in August :)
   — Brenda W.

April 24, 2002
My Plastic Surgeon said that Insurance companies are VERY strick about covering Plastic Surgery. Rashes and back pains are not considered enough in most cases. The need for the abdominoplasty HAS to be considered a "medical necessity" and your apron or panni has to significantly hamper the quality of your life. Mine IS and DOES and my Insurance is covering my Abdominoplasty on May 16th. (Open VBG 06/11/01 - as of today, I've lost 148 lbs!)
   — Cathy J.

April 24, 2002
I checked Aetna's website regarding coverage of abdominoplasty after weight loss. It says they will cover it if "Panniculus hangs to or below the level of the pubis; and The panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs or remains refractory to appropriate medical therapy over a period of 3 months" (taken straight from there website) Also under cosmetic surgery it says they will cover it if "Abdominal lipectomy: When abdominal folds cause symptoms such as chronic pain, dermatitis, or ulceration." Well, I have had lower back pain for a long time, although I am not sure if it is caused by my stomach. I have also never seen my doctor for this because I just figured it was something I had to live with. Any suggestions on what I should do? Should I see my PCP so I can get some documentation started, and, if so, what should I tell him? Thanks for your help.
   — Michele :.

August 27, 2002
Hi Michelle... You may also want to include information from the American Society of Plastic Surgeons (ASPS), who advise that when the surgery is medically necessary it is cosmetic but reconstructive. Check out their website. I'm sorry I don't know the address, but do a search by plastic surgery on any search engine and it should give you their web address. Hope all goes well!!
   — blessednblu

August 27, 2002
I did not have a hanging pannus or a rash. My TT was covered due to muscle separation, hernia, and back pain. My breast lift was also covered. They had some kind of formula for ptosis (amount of droop!) and I definitely qualified for that, again without a rash. I had United Health Care PPO. hugs, Ann RNY 9/10/99 260/130
   — [Deactivated Member]

February 8, 2003
Hi. The last posting was "right on." Back pain, hernia, muscle separation, and dermatitis/rash are good medical indications for abdominoplasty/panniculectomy. For the breasts, a certain amount of tissue weight must be taken out, so as to relieve symptoms. Photos are also usually needed. The droop, or shape of the breasts, is not a factor in determining coverage, as women with quite small breasts can still be "droopy." The INS companies want to see a relief of symptoms (neck, back, and shoulder pain, among others) after surgery, and that is achived by removing the weight. Cheers. JL
   — DrL

June 2, 2003
I just got approved for TT surgery from BC/BS of FL Health Options (HMO). At first they denied me. I appealed the decision and I got approved last week. I had lower back pain documented and pictures showing rash around pubic line. During the Review Panel conference call for my appeal, my PCP explained to them I had rash and I had been treated for it. They did not ask for any documentation in writing regarding the rash and I was approved. You may have a copy of the appeal letter if you would like. Just email me personally at [email protected] Good Luck
   — Jeanette D.

October 2, 2005
Finally...I got my "Tips for Getting Your Plastic Surgery Approved" worksheet on my website. It will help individuals who have medically necessary issues get their plastic surgery covered, at least in part, by insurance. Check www.drlomonaco.com under "Patient Resources"
   — DrL