Many who come to the end of their weight loss journeys often ask “How do I get my insurance company to pay for plastic surgery such as a tummy tuck?” This is a very valid question. Recently I shared with a group of weight loss surgery support patients that my insurance covered a portion of my plastic surgery. Another weight loss surgery patient who works at the same place I do and is ready for her plastic work was shocked. She had no idea our insurance would possibly approve the procedure of having an abdominplasty/panniculectomy done. I see the same types of questions on message boards as well.
Here are some suggestions:
- If you have any type of rash or breakdown of skin, visit your PCP (Primary Care Physician) immediately to have it documented in your file. Do not wait too long or else the rash or area will heal up quickly. Visit the doctor each time these breakouts occur as they will help your case with the insurance company. You may also want to request the doctor’s office keep a picture on file, or to document that a picture was taken and you keep the pictures, along with dates taken. (Note: insurance companies frown upon having a plastic surgeon documenting these types of issues because the surgeon has something to gain from it: your and the insurance companies’ money. Therefore, I would not see a plastic surgeon until after you have documentation.)
- The PCP may prescribe some type of ointment, lotion or other topical cream which usually helps to heal the open or chaffed wound, but does not prevent more from occurring. Most insurance companies require patients to have taken some type of medication to ensure all means of treatment have been exhausted before approving reconstructive procedures as medically necessary.
- It is no longer true that a wls patient must wait 18 months post-op to have any type of plastic surgery done. Some surgeons require that you be at a stable weight for 6 months, and others want you to be within 10 – 15% of your goal bodyweight. For example, if you weigh 130 lbs and have a goal of 120, a surgeon would more than likely go ahead with the procedure as a 10% decrease in body weight would not hinder the surgical result. However, I’ve wondered whether the results would have been different if I had waited longer for plastics. My body seems to have shifted in where it carries weight. If you can wait, it might be worth it and provide better results (unlike me as I grew impatient!)
- Have the Plastic Surgeon take pictures and submit a letter to your insurance company EVEN IF YOU THINK IT WILL NOT BE APPROVED! You may be surprised at the findings. My insurance company had a requirement for medical necessity that the pannula hang AT or BELOW the symphsis pubis (pubic bone) region. I did not think I met this requirement. After all, it is very difficult to see yourself as you really are. Even looking straight on in a mirror, I did not know that my pannula hung down so far. The pictures is where the proof was.
- It is not your responsibility to write the letter to your insurance company. The Plastic Surgeon should write a letter, and he has done this enough to know what is necessary, and should include history, diagnosis codes, any problems that is documented in your PCP’s files such as the repeat rashes and breakdown of the skin and open wounds due to rubbing and chaffing.
- I would not suggest going ahead with surgery in hopes of obtaining insurance approval after the fact. Nowadays, most insurance companies mandate that procedures be PRE-authorized. Failure to do so will result in a denial. If your chosen surgeon does not accept insurance and/or will not write a letter to help you get it covered, find someone else (unless you can afford to pay for it yourself).
- Your insurance company may not approve all of the procedures you need or want. My insurance company, Blue Cross Blue Shield of Tennessee, did cover the panniculectomy. They did not cover the muscle repair as they consider it to be cosmetic. I paid my co-payment for the covered portion, plus the non-covered procedure. I had to choose whether I wanted the muscle repair (which I did!). Be prepared to finance or pay for some of the procedures if your insurance will not, though you can always opt to get it done at a later time.
- Make sure your chosen surgeon has done procedures on weight loss surgery patients. Our skin issues are much different and more complex than working on a normal person. If not, it could prove detrimental not only in your results, but in your health as well. Ask your surgeon to provide pictures of his or her work on bariatric patients. If he/she cannot provide pictures, act hesitant to do this, or if they do not have very many to show you, LOOK somewhere else! Bariatric surgery is a hot commodity today, and plastic surgeons want a piece of the pie! It is a sad fact that some physicians just need a few cases to add to their “reportoire” of gastric bypass patients (somewhat like a trophy or line on their resume). This will make them known in the community IF they are successful and produce good results. BUT, I would not want to be a guinea pig for a surgeon who wants to make a name for himself among the gastric community.
Remember, this is YOUR journey, YOUR body, and YOUR health. Plastic surgery is not to be taken lightly. It is a more difficult surgery than the gastric bypass procedure, and often plastic surgery is glossed over or regarded as an easy, elective procedure. Though elective, the recovery time is not a walk in the park.
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