Insurance to pay for Tummy Tuck??
ExplorinLauren
Posts: 991 Member
I wasn't sure of where to post this...
I've been wanting a tummy tuck for 17 years. I've been waiting patiently
Now, after 4 children, getting healthy, losing weight and getting my ducks in a row.... It will FINALLY happen in March 2013.
I've followed several tummy tuck threads, and I see that SOMETIMES it is covered by insurance, as a tummy tuck or Panniculectomy ....whatever. lol
My question is... How?? Is there something you have to say directly? Does it take months/years of fighting with an insurance company? Do I have to prove something? What do I need to do, or what steps do I need to take, to TRY to have it covered (fully, or partially, I don't care) by insurance?
Thanks!
I've been wanting a tummy tuck for 17 years. I've been waiting patiently
Now, after 4 children, getting healthy, losing weight and getting my ducks in a row.... It will FINALLY happen in March 2013.
I've followed several tummy tuck threads, and I see that SOMETIMES it is covered by insurance, as a tummy tuck or Panniculectomy ....whatever. lol
My question is... How?? Is there something you have to say directly? Does it take months/years of fighting with an insurance company? Do I have to prove something? What do I need to do, or what steps do I need to take, to TRY to have it covered (fully, or partially, I don't care) by insurance?
Thanks!
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Replies
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bump because I am curious!0
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Gahhhhhhh..
Well, I need more answers than this lol0 -
Hi,
I am not an expert in this field. I also live in Canada.
I do have friends in the US that got their Tummy tuck paid for indirectly.
What I mean is that they had to have another small surgery and they got the tummy tuck for "free" after consultation with the doctor
/surgeons doing the case.0 -
Usually you have to have a medical reason for having it done in order for insurance to pay. A history of rashes (yeast infection) under your belly, documented by your doctor would be one example. I would call your insurance company and find out their requirements.0
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Hi,
I am not an expert in this field. I also live in Canada.
I do have friends in the US that got their Tummy tuck paid for indirectly.
What I mean is that they had to have another small surgery and they got the tummy tuck for "free" after consultation with the doctor
/surgeons doing the case.
Do you know anymore info that you can elaborate on? Or how to go about that? lol I see what you are saying... I saw someone that had a panny, and then bc they were in there working already, they got the full surgery. is this what you mean?0 -
Usually you have to have a medical reason for having it done in order for insurance to pay. A history of rashes (yeast infection) under your belly, documented by your doctor would be one example. I would call your insurance company and find out their requirements.
I didn't realize I could just call and ask the insurance company! . lol... Thank you I thought you kind of had to beat around the bush just to have it covered. It seems like a secret society 
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Bump please Need more answers lol 0
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Insurance will pay if there is a medical reason.
So start documenting through your doctor the rashes you get under the skinfold. Bill the supplies to do with it as a medical expense on your taxes. In some people the skin is heavy enough to pull on their back and give them backaches. Again, document it, discuss how it goes away in a pool because the skin isn't pulling on your back any more.
I suspect that in the end mine will get paid for in that way, and I'm pretty sure that my husband's will, because his belly already is severely in the way, and as he loses weight that skin will sag further and get in the way of normal self-care, which is a medical indication to take it off.0 -
Infections,Rashes,Back pain,Shoulder pain,Difficulty running,Difficulty bathing,Yeast Growth,Depression,Boils...I have seen a combination of the following things get approved by Insurance for Tummy Tucks/and or Breast reductions and lifts.I work in a hospital and honestly..with the right DR...a lot can be done with coding and changing things around.I have even seen Dr's with a type of LAYAWAY surgery program..just ask around and tell them your situation...maybe one will think of some "Creative" financing.0
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Thanks guys Helpful info! 0
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Very informative and interesting topic - thank you!!0
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Infections,Rashes,Back pain,Shoulder pain,Difficulty running,Difficulty bathing,Yeast Growth,Depression,Boils...I have seen a combination of the following things get approved by Insurance for Tummy Tucks/and or Breast reductions and lifts.I work in a hospital and honestly..with the right DR...a lot can be done with coding and changing things around.I have even seen Dr's with a type of LAYAWAY surgery program..just ask around and tell them your situation...maybe one will think of some "Creative" financing.
What doctor should I be trying to do this through?? I think that is part of my question.. because I don't know where to start
I have an appointment Monday with my general doctor..And I planned on bringing it up with her. But should I be going with my GP or trying to do this with a plastic surgeon?? What doctor makes the call of how medically necessary it is?? I also worked in a hospital, and private practice.... but it was ER and Neurology.... so not really any help to me lol.. 0 -
Thanks for your answers Truth is, I don't know if I have enough of those problems to medically justify it??
My problems are more that I can't do exercises in proper form, bc my stomach gets in the way... I do have a rash on the side of my stomach, but its only about the size of a quarter. lol ...and I've had it for almost a year...and it never heals. I've tried over the counter creams, and RX, calamine, Desitin, Even straight alcohol..and nothing works. Most of my problems are really just emotionally based. I'm very depressed about it... I can never find clothes. EVER. I couldn't even tell you what size I wear. I have no idea. I try on 16, sometimes it fits, most of the time it doesn't. But at the same time... anything bigger, or even a 16 usually, may or may not fit my stomach but is WAY TOO BIG in all other areas..... I feel stuck. I can't go bigger because it doesn't fit in my thighs lol, but I can't go smaller bc it doesn't fit in my stomach. I just end up not buying anything! And wear the same thing when I leave the house, bc I refuse to buy more clothes while I'm fat!0 -
I also have been interested in this for a while. I am a soon to be 51 year old working mother of 3 young adult children. I have been obese my entire life from grade school on. My first delivery was a c-section and the other two were vaginal. I have struggled forever with my weight, mostly dealing with the emotional stress of it because I didn't do anything about it until about 10 years ago when I had a Gastric Bypass surgery. I dropped 100 lbs and maintained it ( I leveled off at at 85 lb total loss) for quite awhile until about a year and a half ago when I went through some life changing events. I then put on about 40 lbs that I am now trying to get off. I am down 19 lbs from where I started and 14 since I joined MFP in July. I have an appointment tomorrow with a plastic surgeon for a consultation on a tummy tuck. If my insurance does not pay for it, I won't have it done, I will just live with it for the rest of my life. My problem mostly is the lower back pain from carrying around this hanging skin. I used to have the sores but no documentation....I have it under control at the moment with the careful use of medicated powders and yeast infection creams. I cannot do normal excersizes effectively (mostly any abdominal crunchs) and my buying of clothes depends on how well they camoflage the hanging gut I have. I will let you know after tomorrow what my appointment reveals. Thanks for posting this, many are interested and don't know where, how or whom to talk to.0
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Very few people have enough of an issue to justify this medically. If you're searching for reasons, ultimately, you'd be committing insurance fraud. I work in the fraud arena, and these things are examined. People go to jail. Every day.
Don't do it. Save up your money if you want it done.
The only times I've heard of tummy tucks being covered is for those who had weight loss surgery. They get a one time surgery with some insurance plans.0 -
You need a cooperative family doc first.
Your doc will need to document the reasons for a skin reduction surgery. Like a rash, chafing or some other issue. I have a girl friend that lost over 100lbs and our family doctor is helping her get a skin reduction surgery - aka tummy tuck!
My doc is recommending me for a breast reduction. I didnt even ask - it was her suggestion. So come up with your reasons and go see your doc, a lot!0 -
Check your policy to see if cosmetic / reconstructive surgery is covered. Don't be surprised if your policy only covers "medically necessary" procedures and may cap the coverage. (Even with taxpayer funded health care in Canada most purely cosmetic procedures are at the patients expense and are not eligible for medical tax credits)0
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bump0
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Most insurance plans are going to consider this cosmetic and probably won't pay for it unless it is medically necessary. There isn't anything at all YOU can say to convince your insurance company it is medically necessary. You'll have to start by finding a doctor who believes it is medically necessary and is willing to fight your insurance company for you. Ultimately, I think its unlikely you will succeed.0
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Very few people have enough of an issue to justify this medically. If you're searching for reasons, ultimately, you'd be committing insurance fraud. I work in the fraud arena, and these things are examined. People go to jail. Every day.
Don't do it. Save up your money if you want it done.
The only times I've heard of tummy tucks being covered is for those who had weight loss surgery. They get a one time surgery with some insurance plans.
I worked in a medical pre-certification office. We had a team of nurses and a medical director that determined the medical necessity of these kinds of procedures. It happens more often than one would think and it is NOT fraud if approved.
As stated above, there are many reasons that his could be approved for medically necessity. Irritation, rashes, infects from the overlapping skin, the excess skin causing stress on other bones or joints, etc.. Typically the requests we received were from plastic surgeons. They will send your medical records and a letter of appeal requesting this approval. Best of luck!1 -
Some gynecologists are doing them when patients have an abdominal hysterectomy so it is partially covered. Don't think that will help your hubby. lol Wish I haven't already had that surgery!0
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Im in canada, mine will be covered, because its caused from having twins. I also have a hernia and a lot of muscle seperation.0
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The OP is 33 years old and has been waiting for a tummy tuck for 17 years. (Do the math). I don't think you can look at a tummy tuck until you lose most of the weight...and your goal says you have some weight to lose). Why don't you start some lifting to tone up and see how you feel when you lose the weight?0
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Infections,Rashes,Back pain,Shoulder pain,Difficulty running,Difficulty bathing,Yeast Growth,Depression,Boils...I have seen a combination of the following things get approved by Insurance for Tummy Tucks/and or Breast reductions and lifts.I work in a hospital and honestly..with the right DR...a lot can be done with coding and changing things around.I have even seen Dr's with a type of LAYAWAY surgery program..just ask around and tell them your situation...maybe one will think of some "Creative" financing.
What doctor should I be trying to do this through?? I think that is part of my question.. because I don't know where to start I have an appointment Monday with my general doctor..And I planned on bringing it up with her. But should I be going with my GP or trying to do this with a plastic surgeon?? What doctor makes the call of how medically necessary it is?? I also worked in a hospital, and private practice.... but it was ER and Neurology.... so not really any help to me lol..
The "right doctor" the previous poster mentions is probably one I wouldn't want to go to in the first place. The billing she's discussing is called "fraud and abuse" and any good doctor will know that "creative billing" could land them in jail. I'm a medical coder with experience in general surgery - patient's who come in for a "panniculectomy" or tummy tuck will pay for it out of pocket 95% of the time. The reasons you describe in a later post are cosmetic reason and will not warrant the medical necessity needed for the insurance company to pay - especially the larger payors (Humana, BCBS, Aetna, etc).
See if your doc offers a discounted self-pay rate if you pay for it at time of service. Most reputable places have something in place for "self-pay" patients.0 -
A panniculectomy is only covered in cases of "failed" Roux en y (gastric bypass) or when some trauma causes a patient to dramatically decrease in size at a rate faster than which their skin is unable to contract.
The criteria is rather gruesome. In order for an insurance company to cover a panniculectomy, the pannus (the tummy flap that hangs down) must hang so far down that it entirely covers the pubic area and therefore affects activities of daily living. It must ALSO cause bedsores, infections underneath the skin, or whatever word you'd like to use that is unresponsive to three months of consistent medical therapy. (Vaseline over the counter does not count as medical therapy).
The ACTUAL insurance requirements are pasted below:
The insurance company considers panniculectomy/apronectomy medically necessary according to the following criteria:
Panniculus hangs below the level of the pubis; and
The medical records document that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 3 months while receiving appropriate medical therapy (e.g., oral or topical prescription medication), or remains refractory to appropriate medical therapy over a period of 3 months.
The insurance company considers panniculectomy/apronectomy cosmetic when these criteria are not met.
The insurance company considers panniculectomy/apronectomy experimental and investigational for minimizing the risk of hernia formation or recurrence. There is inadequate evidence that pannus contributes to hernia formation. The primary cause of hernia formation is an abdominal wall defect or weakness, not a pulling effect from a large or redundant pannus.
The insurance company considers repair of a true incisional or ventral hernia medically necessary.
The insurance company considers repair of a diastasis recti, defined as a thinning out of the anterior abdominal wall fascia, not medically necessary because, according to the clinical literature, it does not represent a "true" hernia and is of no clinical significance.
The insurance company considers abdominoplasty, suction lipectomy, or lipoabdominoplasty cosmetic.0 -
I agree with the poster that works in the insurance industry, it is reviewed VERY closely ---I've worked in surgery and the only time that it is covered is when it is a medical necessity. The most common that I have seen for the panniculectomy is when the excess skin causes infection underneath and has lead to complications with hip replacements. And to clarify, that is just the SKIN that is removed during that surgery. And yes, for those having gastric bypass, sometimes the panniculectomy is included at a later date---once again SKIN. . . NOT tummy tuck or abdominoplasty.
If you have more weight to lose, continue working towards your goal and in the process save up for the procedure. It is performed by a plastic surgeon. Even if you have some medical necessity, the surgeon will most likely not agree to perform it until you have reached your goal weight (because if you continue to lose, you will simply have more skin that needs removed).
Good luck to you!0 -
I don't think you can look at a tummy tuck until you lose most of the weight...and your goal says you have some weight to lose).
wrong. it's about removing extra skin. and tightening the muscles. now if you have a lot of weight you probably wont have the greatest results. but that hanging skin will be gone.
I had a tummy tuck myself. In fact my stomach is the most awesome thing on my body. Plastic surgeons are artists not just doctors. They can sculpt someone within 20lbs of their goal weight with no problems.
OP - the only thing that would concern me about using the insurance is the quality of surgeon you get. There is a difference! Do your research on any surgeon you consult with.0 -
By the way - I should also post that I'm not just someone who uses google, I've been working in medical insurance claims for 7 years and know way more about it than I'd like to. I realize my answer is unpleasant, but that's the facts. Regardless of what doctor you go to, the insurance company uses their own doctors to make the final decision. You might get one that says it's necessary, but that does not at all mean your insurance company will pay for it.
HOWEVER....
Tummy tucks aren't all that expensive. If it really means that much to you, why not save up $3-5k? It's basically the cost of a nice vacation. It's your body. Do with it what you will. Just don't get mad when a HEALTH insurance company that is created for the purpose of alleviating expenses associated with keeping constituents HEALTHY, ALIVE, and STABLE does not consider it medically necessary. That is very, VERY American of you to even ask this question. And also is a great example of one reason health care costs in the US are so damn high.
That being said, I want a tummy tuck and a boob job. I plan to pay for it all by myself though...0 -
The OP is 33 years old and has been waiting for a tummy tuck for 17 years. (Do the math). I don't think you can look at a tummy tuck until you lose most of the weight...and your goal says you have some weight to lose). Why don't you start some lifting to tone up and see how you feel when you lose the weight?
One sane answer. In 17 years you had enough time to save the money. Second I can't believe you are asking how to do assurance fraud. Lastly lose the fat, give yourself one year or 2 for the skin to spring back the is a good amount of time to have a saving account.0 -
By the way - I should also post that I'm not just someone who uses google, I've been working in medical insurance claims for 7 years and know way more about it than I'd like to. I realize my answer is unpleasant, but that's the facts. Regardless of what doctor you go to, the insurance company uses their own doctors to make the final decision. You might get one that says it's necessary, but that does not at all mean your insurance company will pay for it.
HOWEVER....
Tummy tucks aren't all that expensive. If it really means that much to you, why not save up $3-5k? It's basically the cost of a nice vacation. It's your body. Do with it what you will. Just don't get mad when a HEALTH insurance company that is created for the purpose of alleviating expenses associated with keeping constituents HEALTHY, ALIVE, and STABLE does not consider it medically necessary. That is very, VERY American of you to even ask this question. And also is a great example of one reason health care costs in the US are so damn high.
That being said, I want a tummy tuck and a boob job. I plan to pay for it all by myself though...
THis. Insurance generally doesn't cover these types of surgeries that are not medically necessary...and just based on the info provided by the OP and her profile, I'd be surprised to see any insurance say yes to paying for it.0
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