Question:
What determines medical necessity for abdominoplasty?

I have BC/BS with the State of Maryland; according to customer service, they do not give approval for plastic surgery, instead they say that it has to be medically necessary. So the surgery would be preform and then submitted for approval and payment. Of course, no Plastic Surgeon will take that chance and no get paid. (I can understand the PS position). What BC/BS is not saying is what requirement must be met for it to be classified as medically necessary. I keep getting the run around concerning this inforamtion. Added to this is that I am currently scheduling GYN surgery and wanted to have both done at the same time.    — Lisa D. (posted on July 7, 2004)

July 7, 2004
I have BC BS and have have you submit for approval first. to the medical review board they same way it was before you had the surgery. Did you try to get approval that way.
   — Rosemary L.

July 7, 2004
Never call it plastic surgery, always call it reconstructive surgery. You can get pre-approval for that. I don't know what their specific requirements are, but various insurance companies look at the total amount of weight lost (over 100 pounds for Aetna), an apron that hangs to or below your pubic bone, documented skin rashes and/or lower back pain from the weight of the pannus.
   — mom2jtx3

July 7, 2004
I have BCBS of Michigan. Medical necessity for my approval was to have lost over 100 lbs (158 lbs to be exact),I have chronic yeast infections and rashes under the hanging pannis area and back problems that my chiropractor linked to the hanging skin. My surgeon submited for preapproval before scheduling the surgery. I was approved in 5 weeks and am awaiting my 8/11/04 surgery date. I would get as much documentation as you can from your doctor because the surgeon may not get paid from BCBS, but I think they make you sign paperwork saying you would pay for it if the insurance falls through. Good luck.
   — ckreh

July 7, 2004
The term "medical necessity", regardless of what the treatment is for, means that treatment must be necessary in order to resolve a medical issue (or syndrome of related issues). So, for anything to be covered by medical insurance, it has to resolve a medical problem. Reconstructive surgery can be covered if you can show a severe medical abnormality, or related medical problem. In the case of a panniculectomy, related medical issues include things like chronic yeast infections, rashes, skin breakdown, back aches, decreased mobility, and others. Simply looking bad, creating mental discomfort, mild physical discomfort, or not fitting clothes well are not considered medical issues. And, note that even if you can show medical necessity (do this by documenting with your physician all of the associated medical problems), medical insurance might not cover all of the work you may want done. They may be convinced that removal of excess skin on your abdomen is medically-necessary, but they quite likely won't cover the muscle-tightening that is usually done at the same time. They rarely cover removal of excess skin on the arms, and may give you a hard time about excess skin on the thighs. Breast lifts may be covered if there are medical issues, but will not be covered for appearance sake. The real value of getting some of the reconstructive surgery paid for comes from the hospital and anesthesia charges getting covered as long as some part of the surgery is covered. If you're having other approved gynecological surgery done at the same time, these costs should be covered for that. Of course, it would be best to get as many of the reconstructive procedures covered as possible, just be aware that you are unlikely to get everything covered. Your best bet is to have your PCP certify the medical issues that you are having. My insurance company also insisted on seeing photographs taken by the plastic surgeon. Some plastic surgeons will work with insurance companies, but many will not. If you can find one willing to work with the insurance company, your chances of getting the procedures covered up front improve, and generally the surgeon will wait for at least some of the payment until insurance pays their portion. Best wishes.
   — Vespa R.

July 7, 2004
The insurance company is looking for proof that you have a medical condition related to your excess skin. Simply stating your reason are not good enough. You need to get a diagnois and medical records. For rashes see a dermatalogist and for lower back pain see a Physatrist. A physatrist is a orthopedic doctor but not a surgeon. I saw him 2X and went to PT 4X. I took my medical records to the PS and my medical necessary letters from my PCP and GB surgeon. My PS mailed them with his pre-determination letter and my insurance approved my 6 days after receiving the pre-determination letter.
   — bbjnay