Question:
Are health insurers legally mandated to pay for reconstructive surgery post WLS?

Perhaps this is an "urban myth", but I read on another website some time ago that the health insurer who funds WLS is legally mandated to pay for reconstructive surgery to correct the excess skin, etc. resulting from the WLS. It'd be great if there were true and someone could cite the legal reference---if it's an urban myth, it's a nice one :)    — Lucky B. (posted on August 24, 2004)

August 24, 2004
My insurance is a self funded plan. There was a specific exclusion in our plan prohibiting "panniculectomies and similiar surgeries" after weight loss surgery. I just had an abdominoplasty, as I found a way around this exclusion I think it would be great if the subsequent surgeries would be covered, but I don't believe this mandate is true. (Besides, where would one stop? Everything from a lower body lift to surgery around the eyes would have to be covered.)
   — koogy

August 24, 2004
The only reason my full extended abdominoplasty was covered by insurance was because of my long history of low back problems and a well written letter by an orthopedic surgeon indicating that getting the excess weight off the gut would definitely help my back problems. I have significant degenerative disc disease in 4 discs and have used many different treatments to control the situation. Basically we said that this was a logical step in the management of this condition. It would not make it go away but it would likely help delay surgery or possibly eliminate it because of less pressure on the discs etc. I am 100% confident I would not have gotten this paid without the back problems as I have never had skin infection/breakdown problems, even when I was 442 lbs. Most policies have exclusions for cosmetic surgery so unless you can build a medical need for it, that it will fix or significantly help some other medical condition it won't be covered. The fact that you have lots of skin because of losing weight isn't going to cut it from what I've read. Heck it's only been in the last 3-4 years that reconstructive surgery after breast removal has become covered in most policies. Prior to that if you didn't have the money you were out of luck. <p>I'd be happy if the Federal government would recognize the medical necessity of removing the skin after significant weight loss and allow it as a tax deduction. Treatment for obesity is now recognized as being deductible, well they need to complete that thinking and realize this is a huge problem. At least with a tax write-off it would help defray some of the costs.
   — zoedogcbr

August 24, 2004
I'm sure that it's not true that all health insurers are mandated to cover reconstructive surgery, but I HAVE heard that's the case in California - although this may also be an urban myth, albeit smaller in scope. Supposedly they have a law that insurance has to cover any surgery necessitated by a prior covered surgery and some have interpreted this to mean that plastic surgery is covered. I have no idea if it's really easier to get plastic surgery covered in California, though.
   — sandsonik

August 25, 2004
I don't think so, especially with as much trouble as some folks around here have had getting theirs paid for. But I wanted to clue you in on something else-if you do end up having to pay out of pocket for reconstructive surgery, the IRS has decided that it's tax deductible, so long as it's a necessary follow up to WLS treatment for obesity. And THAT one is true. I looked it up on an IRS website. :)
   — christied