Question:
Opinions wanted - Plastic Surgery questions
Help please! I have had consults with a Plastic Surgeon. I need the works.... tt, arms, lbl, and new boobs. (Could use a face lift too lol) My insurance approved a complete tt, paniculectomy and abdominoplasty. All yhey asked for was a letter from another doctor agreeing with the PS. The surgeon says there is no use submitting for my arms as they will not pay. Well, he did convince me, but then in the back of my mind I know that for sure they won't if I don't ask! Time-wise he says he could combine the two, arms and tt, and gave me an estimate of just under $5000 for the arms. Should I go ahead and do it? I can't afford it and hate to pay it, but I really need the work done. I am burning up in these long sleeves! Or, should I just let him do my tt and see how that goes? I am 5'4" and have gone from 297 to 122 and I'm almost 2 years out (5/30/2002) Thank you all so much... I don't post a lot but I have learned everything I know on here! — Sheryl S. (posted on May 5, 2004)
May 5, 2004
I've been getting the idea from reading all the posts about plastic surgery
and surgeons, that you are lucky if you can find one who will work with the
insurance companies. Many of them just don't want to be bothered with it
all, and I believe it's primarily because they know they won't get paid as
much if they accept the insurance. Did you specifically ask this doctor if
he has submitted for the questionable procedures before, to the same
insurance company you have? Ask him how he knows they will deny you. If
he doesn't want to submit for this, at the very least he could write you a
letter to accompany your own paperwork, and you could submit it yourself.
It certainly can't hurt.
I'm starting to see that this can be an area where we're really "on
our own" unless we find an exceptional PS who cares more about the
patient's health and quality of life than they do about lining their
pockets. And of course, the insurance companies don't help a bit, because
we all know they'll fight you tooth and nail not to have to pay for
something, even if it's medically necessary. It's a jungle out there, and
from what I'm seeing on AMOS, a much worse one than exists for WLS. Good
luck with all of this. Please keep us posted on how it all goes.
— Carlita
May 5, 2004
I just had an abdominoplasty, covered by insurance. I tried for a LBL but
was turned down for coverage. I didn't appeal it. I would still like to
have the lower body worked on, along with new boobs and maybe arm work. In
my humble opinion, I think it's worth the time to try for insurance
coverage on these. This time around, I will appeal if they deny me. I may
be totally wrong, but I think there may be a slight chance, if I am
persistent, that they will cover atleast some more of the surgeries I'd
like to have. I went to the library here and checked under 'appeal' and I
found some great advice and sample letters that have been successful for
other members of our site, so I plan to put some of that info to use and
try for more coverage for additional work. As for the abdominoplasty - I
went ahead and had it alone - instead of self-paying for additional work at
the same time. In my case, the TT was most important to me. It was first on
my wish list, so to speak. I am willing to wait and try for financial help
(insurance) on the other procedures I'd still like to have. I can live with
my saggy arms and droopy thighs for a while longer if it means I could have
any chance at all of having insurance coverage, because self-paying would
be quite difficult for me. I hope this helps!
— Mary W.
May 5, 2004
Obviously, this is a decision that you will have to make for yourself, but
since you asked for opinions, I will offer mine. It seems to me that you
are very lucky to have gotten covered what you have by insurance. I doubt
the insurance company will be any more generous. It is a very rare thing
to get arms covered because they are almost always a cosmetic procedure.
The arms do not usually cause any MEDICAL issues (psychological, no doubt),
and so MEDICAL insurance will usually not cover them. Being hot wearing
long sleeves is not a medical problem. You could wear sleeveless, reasons
the insurance company, but you choose not to because you don't like the way
your ams look uncovered (and looks are by definition cosmetic).
Abdominoplasties are sometimes covered because the extra hanging skin
causes medical issues with rashes, back pain and mobility limitations.
Most of the time muscle-tightening is not covered because that again is a
"looks" issue, not a medical one. So, of course, you could try
to get the brachioplasty covered, but unless you can prove medical
necessity, I wouldn't count on it being paid for. You could go ahead and
have this plastic surgeon do all the work, and pay the surgeon fee for the
brachioplasty out of pocket. At least your hospital stay and anesthesia is
covered by insurance for the other work at the same time. If you wait to
have the arms done separately, and insurance does not cover it, then you
will have not only the surgeon's fee, but all the hospital, anesthesia and
related costs to pay out of pocket as well. I would think that if you
believe you have a shot at insurance covering the arms that you should try
to get that approved before having the rest of the surgery. If it is
covered, then you can decide if you want to go through two separte
surgeries. If it's not covered, then you might want to have all the work
done at the same time and save yourself a chunk of money. Best wishes
whatever you decide to do.
— Vespa R.
May 5, 2004
Congratulations on your upcoming ($$$covered) surgery!! Yes, do the
breasts/arms together. I did and it was wonderful to have that region
taken care of. I went on to have a TT and thigh lift and that was also
really effective. Read my profile and check out my website for more
detailed info...Diane N
www.WeightlossSurgery.ws
— DianeN
May 5, 2004
As Carlita mentioned, we are on our own for insurance stuff. I just went to
a plastic surgeon having beforehand researched the insurance criteria for a
TT which I determined I easily met. The surgeon looked at me and said that
insurance 'rarely' pays for these things trying to discourage me from
trying for it. I convinced him to try to get a LBL lift covered by
insurance. He knew I was interested in paying the difference between a TT
and LBL if the LBL didn't get approved. Well, I just got back the approval
for the TT on the first try. While I'm happy that the TT is covered, there
was no mention of the LBL at all - so he never even tried for it. I'm sure
it's because he would make more money on me if insurance didn't pay for the
LBL. I'm so mad that I'm going somewhere else. Bottom line is - if you
think you have a shot and even if you don't think you have a shot at
getting it covered, I say try! And, if you end up paying for your arms
yourself, you will save a lot of money by combining surgeries. Long answer
to a short question - sorry.
— Yolanda J.
May 5, 2004
In my opinion you should have the arms done at the same time if at all
possible. My reasoning behing this is because if you do it later you will
pay more. You'll have to pay the anesthesia fee and the facility fee which
would be included if you do it at the same time. Just something more to
consider. Good Luck
— Carla B.
May 5, 2004
I think your surgeon was wrong in not submitting your arms. I used to do PS
medical review and you can't believe the things that got approved. I also
would appeal to the last appeal level. The other question, it makes sense
to have it all done at once, but it will be a harder recovery. Best of
Luck!
— ZZ S.
May 5, 2004
I have a friend that is having her arms done 5/10 of this year and her
insurance is paying for it. She has Humana Insurance so if I were you I
would definitely check into it before I paid out of pocket for it...Good
luck!!
— Sharon1964
May 5, 2004
I just wanted to throw in my 2 cents concerning your remark about burning
up in long sleeves. Before my brachioplasty, I went sleeveless. I wasn't
bothered by my arms until I went to a concert and found my arms still
flapping long after I stopped clapping. I had my arms done with a breast
lift and tummy tuck last September. Now, seven and a half months later, I
am so intimidated by the scars on my arms, I rarely wear short sleeves, and
never go sleeveless. My surgeon considers my scars to be far superior than
he anticipated, yet I hide my arms much more now than I did before surgery.
Hopefully, I'll feel differently next year, when all the pinkness of the
scars is gone, but for now, I don't feel it was worth all the pain and
money. BTW - we didn't even bother to submit the arms or breast lift to the
insurance company. Just the fact we finally got them to approve the TT was
a small miracle (and they are now refusing to pay as they consider the TT
to be a cosmetic procedure - but that battle is an entirely different
issue).
— Cyndie K.
May 5, 2004
I'm going to post this even though I know it is probably an unpopular view.
I think there is a rare exception when plastic surgery procedures are
medically necessary. If your doctor has said that insurance usually or
will not pay for this, then more then likely it is because he knows it is
not medically necessary. The plastic surgeon I finally chose refused to
try for insurance coverage. I think that was the ethical thing as I was
not experiencing any medical problems. I did however go to another plastic
surgeon who was going to write a letter of medical necessity citing the
rashes and mobilization problems I have been having. (His words. I never
claimed any of those things). He never did it because I told him that my
insurance company would not preapprove, so he wanted his money up front. I
shopped around and chose another surgeon. Someone said they believe that
surgeons do not submit because they get more money if it is self-pay. They
probably do get more if its self-pay, but they also probably get less
clients when they only go self-pay. So let's not pretend greed is the only
reason they refuse to submit to insurance companies. I am for combining
surgeries when it is feasible. A TT and arms should not be a hard
recovery. You can either self-pay for the arms and let this doctor do it
or try to find a doctor who will submit both to the insurance company.
Personally, I question doctors who are willing to "fudge" to get
patients.
— Lisa N M.
May 5, 2004
You can submit for approval for the arms but it is the longest longshot of
the PS's unless there is clear evidence (photos) of rashes and infections
etc. No matter how you look at it 99% of the time it is being done for
cosmetic reasons. We don't like the way they look or hang etc. My arms
are very batwinged and hang like a turkey neck when hanging down next to my
body, yet I will not waste my time or my PS's time in going for insurance
approval. They denied the lateral thigh portion of my lower body lift and
covered the full extended abdominoplasty. If the thighs were not covered
there is no way the arms are.
<p>All this said you can try but if your PS isn't on board then he's
not going to write a decent letter trying to convince them. He will do a
cursury job at best. Normally I would say do the arms with the TT but
truthfully his price is VERY high considering it is a 2nd procedure. My
cost to do arms as a standalone procedure is less than $5000 and as a 2nd
procedure around $3000-3500. I'd be asking for a breakdown of those costs
as it seems very high to me. By law he has to reduce his fee by 50% for
the 2nd procedure. Since he is submitting to insurance for the first
procedure these rules apply. If there was no insurance coverage then he
can do what he wants. You should also only be paying for your portion of
the hospital or surgery cente costs. The arms are usually a 1-1/2 to 2 hr
procedure. Make sure that the hospital is giving my a fixed price and not
going to bill things piece by piece. If it's hiw own surgery center then
$5000 as a 2nd procedure is highway robbery, as he can control his facility
costs a ton more than hospitals and independent surgery centers. Maybe you
need to check out a few other PS's and see what their prices are for a
comparison. I realize prices vary across the US but this just seems high
by at least $1000.
— zoedogcbr
May 5, 2004
I would go ahead and have them done, but $5,000 seems awfully high. My arms
cost $3,000 and that included the facility and anistioligist(sp). Since you
will already be there and already be knocked out it shouldn't cost that
much for him to do the arms, it only takes about 1 hour more.
— Tawnda C.
May 5, 2004
I agree with the previous poster about $5000 for your arms being too
expensive - especially if that's only for his work and doesn't include the
surgery room and anesthesia. If so, then he obviously is trying to make
back some of the money he's going to lose by having the insurance covering
your tt. He will get a drastically reduced fee for your tt. My doctor's
charge is $4200 just for his fee for an abdominoplasty. My insurance paid
him $864. The rest he had to write off. There is NO financial incentive
for him to submit ANYTHING to the insurance company to get it approved. I
would still make him write a letter of medical necessity for all of your
other work and submit pictures to the insurance company to see if they
would cover anything else. I have made my PS submit everything to my
insurance company. I also have a flexible spending account through work
and I take out the maximum of $5000 pre-tax and it is paying for the
majority of my inner thigh surgery in a couple of weeks. Flexible spending
accounts only require a letter of medical necessity from your doctor to be
covered. Granted, you are paying for this surgery but the fact that you
can take the money out pre-tax is also saving you about 15% and puts you in
a lower tax bracket at years end. I'll be doing this again next year when
I get my breast lift due to severe ptosis of the breasts. Just another
avenue for people to consider.
— Patty H.
May 6, 2004
Original poster here.... You all just can't imagine how much I appreciate
your thoughtful responses! To clarify, yes, the $5K was including hospital
and anesthetic. ($1875 hosp, $318 anesth, $2700 surgeon) This was his
estimate. He says the hospital charges by the hour or portion of an hour.
So the fact that I'm already there doesn't matter as much, as I would pay
for the time spent on the arms in any case, but the prep time and recovery
could be billed to insurance so there would be some benefit to combining
procedures. As much as I would like to get the arms done now, I think I
will do the TT now, and see how it goes. I could combine the arms with
breasts later. I think the more "Yesses" I get from my insurance
prior to asking for the arms, the better chance I have of getting it
approved. I know a lot of people think that I (or anyone else) am
"lucky" to get any PS approved. I do not feel that way. I had a
medical procedure (WLS) for a life threatening disease/illness (morbid
obesity) and as a result of that treatment I need RECONSTRUCTIVE surgery. I
don't see it as any different than when a woman has a breast reconstruction
after surgery for breast cancer. I am going to ask for the LBL next, then
the breasts and arms. Thank you all again!! And wish me "luck"!
— Sheryl S.
May 7, 2004
I've tried to make a similar comparison, but realize it is unfair to
compare the disfigurement a woman suffers from having her breast cut off
and reconstructed to having sagging skin from weight loss. Should
insurance also have to pay to try and have stretch marks removed? That is
a result of the disease of morbid obesity too. Our skin is still there and
intact and for all purposes functions as it should unlike a woman who has
had her breast removed. When there are medical reasons for removal for
skin, I think that insurance should pay for it, but I don't agree when
there are not medical reasons. I don't agree with doctor's submitting
letters which are untrue to try and get something covered. This country is
in a health care crisis and abuse of health insurance is just going to make
things worse. I also believe that with so many people trying to get
coverage for non-medical reasons will only make things harder on those who
really do need it for medical reasons.
— Lisa N M.
May 7, 2004
Go for the letter on the arms if you don't have a deadline to meet for
surgery ! You should always try combining cases (as many as your surgeon
is comfortable with) as this saves on time, recovery, anesthesia exposure,
etc.
— DrL
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