Insurance to pay for Tummy Tuck??

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  • grannisue
    grannisue Posts: 37
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    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!
  • twinmama1987
    twinmama1987 Posts: 566 Member
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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.
  • mountainmare
    mountainmare Posts: 294 Member
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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?
  • boggsmroz
    boggsmroz Posts: 20
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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.
  • laprovocateur
    laprovocateur Posts: 128 Member
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    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.
  • info_nrs
    info_nrs Posts: 102 Member
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    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!
  • blushingmama
    blushingmama Posts: 111 Member
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    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.
  • laprovocateur
    laprovocateur Posts: 128 Member
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    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...
  • Yanicka1
    Yanicka1 Posts: 4,564 Member
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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?

    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.
  • _Wits_
    _Wits_ Posts: 1,286 Member
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    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.
  • _Wits_
    _Wits_ Posts: 1,286 Member
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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?

    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.

    This too.
  • DopeItUp
    DopeItUp Posts: 18,771 Member
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    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!

    Sounds like you're putting the horse before the cart here. Who has trouble finding clothes that fit perfectly? Everyone does. You're essentially trying to scam the insurance company out of money for a cosmetic procedure and you're more or less blatantly admitting it right here.

    You've got a bunch of weight to lose still, I'd hit your goal weight and then wait 2 years or so to see how things tighten up. Then maybe reassess the situation. Use the opportunity to start saving $$ in the meantime!
  • blushingmama
    blushingmama Posts: 111 Member
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    I suppose it all depends where you live & the quality of the surgeon, but tummy tucks are expensive.

    Plan on spending 12-20K
  • snailhead
    snailhead Posts: 10
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    I had a tummy tuck in July after losing 90 pounds. The skin was definitely loose and bothered me, but it wasn't horrible. My doctor and his office staff said that they have seen people come in with full aprons of loose skin hanging down, covering...well, you know, and they would still have to go back and forth with health insurance to cover a portion of it. Even if the doctor writes a note to the health insurance company saying there is a need for it because it's causing a rash, you still need to fight it with them. It's always worth a try, but given I did not have a ton of loose skin, I decided not to bother fighting with health insurance so I just took out a 6 months same as cash loan to pay for it. Loving the results! Very worth it!!!!
  • ilovedeadlifts
    ilovedeadlifts Posts: 2,923 Member
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    why on earth does insurance cover people's laziness?
  • laprovocateur
    laprovocateur Posts: 128 Member
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    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.

    Unless she's tucking tummy flab into the pants of her size 8 skirt (because there's no way she'd be able to wear jeans if she actually qualified) then she will not be approved. If she is, it's because she has an LPIP plan and they'll deny the claim on the back end and leave her with a huge bill.

    Pay cash for cosmetic stuff. It's cheaper, it's legit, you get better care, and you actually get much more talented surgeons.
  • snailhead
    snailhead Posts: 10
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    I suppose it all depends where you live & the quality of the surgeon, but tummy tucks are expensive.

    Plan on spending 12-20K

    It does depend on where you live. In Delaware, I paid a little over $6,000 which was the average estimate among plastic surgeons in the area.
  • jillybeanruns
    jillybeanruns Posts: 1,420 Member
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    why on earth does insurance cover people's laziness?

    This. Your extra skin is because of what YOU did and I think it's BS you're looking for insurance to cover it.
  • Pedal_Pusher
    Pedal_Pusher Posts: 1,166 Member
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    Call the insurance company. No, seriously.
  • LAWSBIGGAL
    LAWSBIGGAL Posts: 47
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    I know someone who got it covered by insurance but it was because her stomach was rubbing and causing sores. That's why they covered it. They found it "medically necessary".

    Editted to add: She had already lost most of her weight.

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