Insurance for excess skin

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  • hekla90
    hekla90 Posts: 595 Member
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    jgnatca wrote: »
    Canadians can get breast reduction surgery, as it can become a back issue. There is a cosmetic component but there's also the person's quality of life. My girlfriend survived breast cancer (stage three) fifteen years ago. She qualified for cosmetic repair last year and the surgeon reduced her surviving breast and reconstructed the other. Very soon after surgery, nagging back problems went away. Was this cosmetic or medically necessary?

    So can those in the US. It is covered by insurance. Getting breast implants after a mastectomy is not medically necessary, it is absolutely cosmetic. It is generally covered by insurance here as well. Medically necessary means you will suffer some type of physical consequence if it's not done. I find that crazy it took 15 years to get that approved. Definitely would not have taken anywhere near that time to get approved and completed here.

    While cosmetic I view that as no different than if someone was in a car accident and needed facial reconstruction. There's nothing wrong with my tatas, just smaller after losing weight my insurance shouldn't have to pay for that for instance.

  • xxxibgdrgn1981
    xxxibgdrgn1981 Posts: 10 Member
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    From your pic u look amazing !!!!!!!!!!!!!!!!!
  • mccindy72
    mccindy72 Posts: 7,001 Member
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    hekla90 wrote: »
    jgnatca wrote: »
    Canadians can get breast reduction surgery, as it can become a back issue. There is a cosmetic component but there's also the person's quality of life. My girlfriend survived breast cancer (stage three) fifteen years ago. She qualified for cosmetic repair last year and the surgeon reduced her surviving breast and reconstructed the other. Very soon after surgery, nagging back problems went away. Was this cosmetic or medically necessary?

    So can those in the US. It is covered by insurance. Getting breast implants after a mastectomy is not medically necessary, it is absolutely cosmetic. It is generally covered by insurance here as well. Medically necessary means you will suffer some type of physical consequence if it's not done. I find that crazy it took 15 years to get that approved. Definitely would not have taken anywhere near that time to get approved and completed here.

    While cosmetic I view that as no different than if someone was in a car accident and needed facial reconstruction. There's nothing wrong with my tatas, just smaller after losing weight my insurance shouldn't have to pay for that for instance.

    Actually the qualification was changed a few years ago, so that the reconstruction after mastectomy is considered part of the coverage. There was some litigation I believe, but it was proven that the emotional scarring the women suffered after going through not only facing cancer, but also suffering the loss of one or both both breasts, made the procedure medically necessary.
  • jgnatca
    jgnatca Posts: 14,464 Member
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    I might point out that there might have been more than one factor in place for the fifteen year wait. First of all she needed a clean bill of health. Second, she lost significant weight before going for surgery. And finally I don't know how long it took her to make up her mind.

    The rebalancing of her breasts cured her of chronic back pain. That's more than cosmetic.
  • Hearts_2015
    Hearts_2015 Posts: 12,031 Member
    edited November 2015
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    jgnatca wrote: »
    Excess skin after significant weight loss is a common problem. I often point to this video to illustrate.

    https://www.youtube.com/watch?v=CpKDteQ3FIQ

    Here in Canada under public health care, some skin removal is typically covered, as the excess folds of skin can be difficult to keep clean. Believe me, our public insurance group is very conservative about things like that. I have seen cases even in the United States where insurers have covered this sort of skin removal. I'm sorry I can't give any experience on which insurer would be better. I think you would have to investigate each one.

    Youtube vid is wonderful....what a cool guy :) He's very inspiring! OH, I hadn't realized He was a member here on MFP
  • vczK2t
    vczK2t Posts: 309 Member
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    i work in the health insurance industry, for a health insurance company. I can assure you that most, if not all, insurance companies AREN'T going to cover cosmetic surgery. that's what you are describing, is removing excess skin to look better. you need to call the insurance companies to find out if surgery to remove excess skin is covered or not. NOBODY on MFP works or knows the ins and outs of ALL insurance companies. do your homework and find out which insurance policy works best for you.
  • vczK2t
    vczK2t Posts: 309 Member
    edited November 2015
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    hekla90, "Medically necessary means you will suffer some type of physical consequence if it's not done." that is NOT the meaning of medically necessary. medically necessary means "...would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms....." and those criteria have to fall in the insurance company's guidelines, not the doctor's.

    also, breast implants after a mastectomy are not "cosmetic". it is reconstructive surgery. THAT'S why most insurances cover it.
  • MorganMoreaux
    MorganMoreaux Posts: 691 Member
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    Am I the only one slightly offended by the mention of insurance paying breast implants for cancer survivors is even being compared for lose skin removal because someone lost weight? I'm not trying to be mean, but these are two completely different things. Whereas obesity and thus the need to lose weight resulting in lose skin is completely preventable, breast cancer is not related to lifestyle choices that the person inflicted on themselves, and has great physical and psychological ramifications. I honestly find the comparison gross.

    That being said, kudos OP for all the hard work. It is unfortunate that insurance will not cover those procedures, because it definitely affects quality of life. I feel that insurance companies in the United States are way to profit driven, to the detriment of the American people. I won't get started on the pharmaceutical industry. OP. - I don't know your financial situation, but if at all possible try to find a doctor that will advocate for you. They may be able to present the necessity of this procedure to the insurance company where they will cover it. I haven't had to "fight" for any large procedure, but I frequently do so for smaller tests etc that I want done. I have a wonderful doctor that guides me in what I should say so that the tests are covered. Try to find people online who have had this procedure covered by insurance and find out what they did/said. Personally, I think the day to do inconvenience of the lose skin along with the psychological components of having it should be sufficient, but that's neither here nor there.

    Good luck!
  • jgnatca
    jgnatca Posts: 14,464 Member
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    Hearts_2015 wrote: »
    jgnatca wrote: »
    Excess skin after significant weight loss is a common problem. I often point to this video to illustrate.

    https://www.youtube.com/watch?v=CpKDteQ3FIQ

    Here in Canada under public health care, some skin removal is typically covered, as the excess folds of skin can be difficult to keep clean. Believe me, our public insurance group is very conservative about things like that. I have seen cases even in the United States where insurers have covered this sort of skin removal. I'm sorry I can't give any experience on which insurer would be better. I think you would have to investigate each one.

    Youtube vid is wonderful....what a cool guy :) He's very inspiring! OH, I hadn't realized He was a member here on MFP

    He is???? How COOL is that! Shout out, young man, I love your videos!
  • jgnatca
    jgnatca Posts: 14,464 Member
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    @MorganMoreaux , obesity is now identified as a disease. Do we make people pay for their own health coverage because they "inflicted it upon themselves", like smokers with COPD, or the sexually active with vaginal or throat cancer?

    For significant weight loss, the excess skin literally hangs and can get in the way of everyday activities. It is also difficult to keep clean and dry so thus can be susceptible to fungus or other infections.
  • pfgaytriot
    pfgaytriot Posts: 238 Member
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    Great job on the weight loss! That's an amazing amount of weight to lose. Congratulations!

    My wife lost a significant amount of weight, as did I, but she was left with a significant amount of skin while I was not. She's was medically approved for the surgery when she had to have an emergency appendectomy, but we'll be holding off for a year or so because we want to have kids first.

    Below is a list of criteria that has to be met before Anthem (my insurance provider) will cover skin removal, aka Panniculectomy and Abdominoplasty. Note the significant weight loss circumstances before deciding to move forward with skin removal surgery.
    Panniculectomy is considered medically necessary for the individual who meets the following criteria:

    The panniculus hangs below the level of the pubis (which is documented in photographs); AND One of the following:
    • there are documented recurrent or chronic rashes, infections, cellulitis, or non-healing ulcers, that do not respond to conventional treatment (for example, dressing changes; topical, oral or systemic antibiotics, corticosteroids or antifungals) for a period of 3 months; or
    • there is documented difficulty with ambulation and interference with the activities of daily living;
      AND
    • Symptoms or functional impairment persists despite significant* weight loss which has been stable for at least 3 months or well-documented attempts at weight loss (medically supervised diet or bariatric surgery) have been unsuccessful; AND
    • If the individual has had bariatric surgery, he/she is at least 18 months post operative or has documented stable weight for at least 3 months.

    *Significant weight loss varies based on the individual clinical circumstances and may be documented when the individual:
    • Reaches a body mass index (BMI) less than or equal to 30 kg/m2; or
    • Has documented at least a 100 pound weight loss; or
    • Has achieved a weight loss which is 40% or greater of the excess body weight that was present prior to the individual's weight loss program or surgical intervention.

    Source: https://anthem.com/medicalpolicies/policies/mp_pw_a053328.htm

    Some insurance companies may have different criteria, but the above list is what Anthem needs before agreeing to cover the procedure.
  • MorganMoreaux
    MorganMoreaux Posts: 691 Member
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    jgnatca wrote: »
    @MorganMoreaux , obesity is now identified as a disease. Do we make people pay for their own health coverage because they "inflicted it upon themselves", like smokers with COPD, or the sexually active with vaginal or throat cancer?

    For significant weight loss, the excess skin literally hangs and can get in the way of everyday activities. It is also difficult to keep clean and dry so thus can be susceptible to fungus or other infections.

    I think the excess skin removal should be covered by insurance- I said as much in the second paragraph. I don't think it should be compared to reconstructive surgery for breast cancer survivors. Regardless of whether it's classified as a disease or not, it is brought about by lifestyle choices where as breast cancer is not lifestyle related, and I don't agree with the comparison.
    Also, your response doesn't make much sense as I was referencing the comparison itself. I was not addressing whether or not obesity and related treatments should or shouldn't be covered by insurance, which, if you read the second part of my post, you would know where I stand with that :)

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