Question:
Need Input......PLEASE Help plastic

I consulted with a plastic surgeon yesterday and was told that I needed a full abdominoplasty. She did not feel that I would benefit much from a panniculectomy alone. She did feel that it was medically necessary and said that she could feel that my muscles definitely needed to be tightened. However, she will not ask my insurance company (HUMANA HMO) for reconstructive abdominoplasty, only reconstructive panniculectomy. She said that always deny and never pay for abdominoplasty but would approve panniculectomy. She said she's never had one come back approved. She said she would agree to accept the payment for the panniculectomy from insurance and I will have to pay the difference out of pocket. Does this sound reasonable or should I seek another opinion since she agrees that it is medically necessary? My insurance company says that they will pay for whatever is medically necessary but there is only one code for both procedures. The plastic surgeon agreed that there is only one code but the code only covers panniculectomy and the insurance company expects them to do the rest for free. I've already cancelled one appointment with another p/s because he refused to accept any payment from insurance whether they covered it or not. I'm not sure what to do. Does this sound reasonable or is it unreasonable that she will not even try to get the whole thing covered under insurance. She told me if it was approved, I would have 90 days to decide or the process had to be started over. Any insight on this matter would be GREATLY appreciated. Thanks.    — THE NEW M. (posted on April 8, 2004)

April 8, 2004
I don't know what your financial situation is but if she is willing to submit for insurance on part of, and knows the other is futile to try, I would suggest you pay for the part that is not covered. I am currently reviewing my options on this subject also. I haven't seen a ps yet because I am only 6mths postop but I have already figured that insurance will not pay for everything I want done so I am saving up before I see a surgeon. I figure I will need a couple of thousand at least so it will take me a few mths of scraping everything I can out of my budget to try to get that much together. Good luck to you and God bless you on your journey.
   — tntwildlife77

April 8, 2004
I had a very similar consult last week. I am planning to get a second opinion, just because I think that's always a good idea. The plastic surgeon I saw told me basically the same thing that yours told you. Insurance might cover a panniculectomy because they are dealing with the excess skin issues (rashes, back aches from carrying the weight in front). The muscle-tightening part is not usually medically necessary--that part might be mentally necessary to get the look we want, but doesn't solve any medical issues. I found it perfectly reasonable to submit for panniculectomy, and then for me to pay for the additional costs of the muscle-tightening part. I fully expect to get the same recommendation from the second surgeon. I called about six different plastic surgeons and most won't even deal with insurance at all, not even to bill or provide a letter of medical necessity. I think you got a pretty good response in that yours is willing to work with insurance at all. If you're not comfortable with the arrangement, then try to find a surgeon who will submit for a full abdominoplasty and see what happens.
   — Vespa R.

April 8, 2004
I also got 2 opinions and I am sure glad I did. The first guy said I didn't have muscle damage and only needed a "mini-panni which would remove skin above the belly button only. The 2nd surgeon said he could feel an area of muscle damage and said I needed the abdominoplasty. His office woman said she didn't think my insurance (Coventry) would cover any of it. I asked her to submit it anyway. I havent heard back from the insurance co. and have already pre-paid for the abdominoplasty and breast lift. I figure I might as well TRY to get insurance to pay, nothing's lost. My surgery is scheduled for April 23,04
   — Connie M.

April 8, 2004
My PS did a full abdominoplasty, even though he was only paid for a panniculectomy. He wanted me to look my best plus he also knew I would need more work (don't I ever!!) so he knew he would have a repeat customer for things that weren't going to be covered by insurance (my arms and inner thighs). Having had the abdominoplasty, I couldn't imagine just having the panniculectomy as I wouldn't have been happy with the results. I have a tiny flat belly now. No overhang. I think it's worth the extra money to have the job done right the first time. I would pay the extra money out of pocket for the procedure.
   — Patty H.

April 10, 2004
Hi. Your insurance situation sounds familiar...companies often will not cover "non-medically necessary" surgeries, which may include the muscle tightening and sculpting of an abdominoplasty. Personally, I have done 2 panniculectomies...ever. I have also seen twice that number in the past 6 months who desire a revision...not that there's anything "wrong" with the operation...it just has a limited scope and limited results. Look at pictures, pictures, pictures. See what's best for you. Maybe a panni IS an OK option for you. The added expense of a well-done abdominoplasty is well worth it, especially since it's nearly impossible to resculpt very well after a panniculectomy.
   — DrL