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WUCRew83

What constitues medical necessity for plastic surgery

14 posts in this topic

What are some reasons that may constitue medical necessity to have a tummy tuck, arms, breasts, any typeof plastic surgery. I am 99.9% sure that my insurance will not cover any type of surgery, but there is so much excess skin I can't see my hoo-hah (sorry for the visual). I scheduled a consult with a doctor and I will see what he has to say, but just curious what worked for others. I have Aetna insurance.

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I am really curious about this too. This would be a good question to direct to the plastic surgeon on here who has his own section. I, too, have AETNA and am hoping they will cover my breast reduction & even possibly my tummy tuck. I have a consult with the plastic surgeon next month and one of my questions for him is what do I have to do on my end to get insurance to cover it--do I have to start documenting things, do I have to show up at my doctor's office every month complaining about skin chafing, rashes or back aches? :eek:

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I just checked Aetna's website and it seems they do cover excess tummy skin removal if if hangs below the pubic area AND you have recurring skin infections, chaffing etc. etc.

They cover other procedures based on medical necessity - you can read their guidelines here: Cosmetic Surgery

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The big thing is the rashes and such have to be documented. I have a friend who got surgery covered but she had been complaining about her rashes for a year.

I also have Aetna and I'm going to be watching very carefully and if I get any rashes, discomfort, etc make sure the doctor notates it for the future!

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I just checked Aetna's website and it seems they do cover excess tummy skin removal if if hangs below the pubic area AND you have recurring skin infections, chaffing etc. etc.

They cover other procedures based on medical necessity - you can read their guidelines here: Cosmetic Surgery

Thanks so much for posting this--it's really helpful.

Since I paid out-of-pocket for my gastric bypass (my Aetna plan specifically didn't cover WLS since I am not insured by an employer, but I purchase my own health insurance as a single private person), it would be great if Aetna would pay for my plastics. Everyone I know who has ever gotten a breast reduction (my mother, sister & various friends) has had it covered by insurance. Seems that's the easier one to get them to pay for, versus the tummy tuck. We shall see .... but here's hoping!

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Thank you for letting the pre-ops realize that these things should be documented in case the need arises later. I have a really big "apron" and have the fear of lots of hanging skin once I lose weight... something that is helping me now is thinking I'll just pull on those tight spandex panties that go up under my breasts lol which doesn't help my husband, but maybe I'll just tell him not to look later, too!!

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Breast reduction is covered but they will probably insist that you see a chiropractor because the assumption is that you are having excessive back pain and have large welts on your shoulders from the weight of your breasts.

Tummy tucks will be covered but it has to be medically necessary, Excessive skin can lead to rashes, infections, ect. So you want to see your doctor for every rash and any other problems you have with excessive skin. If they approve that part of the surgery and you want additional tucking, you will have to pay for that yourself but the hospital will be covered because of the tummy tuck.

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This is great news, haven't had surgery yet but I am scheduled for next month. I have Aetna so I am going to check and hopefully they will cover when the time comes since they are covering my surgery.

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(Documenation - the more the better) All of this would help. I also have AETNA. I went in for a consult on January 3rd I wanted Breast reduction, TT and scar removal from Bypass surgery that had started to Keloid. I was approved for the Scar removal and the breast reduction very quickly. In fact, my surgery was on 1/17/11. I got an approval in one week and I am very happy with the results. The lady that does the approvals at my Dr's office says that AETNA was approving a lot of things lately. I put in for an appeal for my TT, but its not called that NO insurance company will cover TT that's cosmetic. What they will cover if Dr saids it is medically necessary is a panniculetomy. I hope I spell that correctly. It is when you have extra skin like an apron hanging, rashes, or skin breakdown. Let me know if you need more info. You can also email me, glad to help and Good Luck.

I am really curious about this too. This would be a good question to direct to the plastic surgeon on here who has his own section. I, too, have AETNA and am hoping they will cover my breast reduction & even possibly my tummy tuck. I have a consult with the plastic surgeon next month and one of my questions for him is what do I have to do on my end to get insurance to cover it--do I have to start documenting things, do I have to show up at my doctor's office every month complaining about skin chafing, rashes or back aches? :eek:

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I had a TT and Aetna covered the lower portion of the TT (removal of the panni) and that helped cut down on the cost. I had some documentation (not much) but they approved it in 2 weeks. I was thrilled!!!! The TT is amazing and totally worth the money even if you have to pay out of pocket. My surgeon told me that they never have anything else covered other than the panni and it is a waste of time to even try. I did my TT, hernia and lipo on legs this winter. I plan on doing my arms and breast this spring and my legs next winter. I would love to submit my legs to see if it could be covered. I have more skin issues on them than anywhere. Please post if you have ever had your legs covered. Thanks!!!

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The big thing is the rashes and such have to be documented. I have a friend who got surgery covered but she had been complaining about her rashes for a year.

I also have Aetna and I'm going to be watching very carefully and if I get any rashes, discomfort, etc make sure the doctor notates it for the future!

I have HealthPlus of Michigan and I was told by my surgeons office to make sure to document any skin irritations or rashes due to excess skin and my insurance will cover the cost of surgery to remove the skin; however, they will not cover it if only for the reason that I "don't like the way it looks" for example.

Also, they will not cover breast augmentations.

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I received a letter from my insurance company approving my WLS back in January and the very next day I received another letter stating that any cosmetic surgery occuring from the WLS would not be covered. I thought that was pretty funny. I'm still too early out to tell if I'll need and tummy tuck due to infections/rashes, however I'll make sure they cover an eye lift before a tummy tuck!!

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It is really important that we understand exactly what we mean by a "tummy tuck" and if you're talking with your insurance company, surgeon etc., you need to be specific. Here are the basics:

A Panniculectomy involves removal of the lower tummy skin and fat overhang. Nothing else. It will NOT flatten your tummy. It is done to allow people to clean themselves better and prevent skin infections in the groin fold. It is NOT a cosmetic operation.

An Abdominoplasty is a much longer and more extensive operation which will remove ALL the loose tummy skin, will tighten separated muscles, narrow the waist, lift a sagging Mons pubis and relocate the belly button in the process.

My insurance covers for a panniculectomy based on medical need - not a cosmetic one.

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Tummy tucks will be covered but it has to be medically necessary Excessive skin can lead to rashes, infections, ect.

This blanket statement is a bit misleading though- it depends on the insurance one has and how that is written. "Medically necessary" for some insurance would include repeated rashes, and what not, or the size of the pannus, if it's hanging below the pubic bone. But what is 'medically necessary' for one is not the same for all.

My insurance specifically excludes -any- plastic surgery AT ALL due to WLS. There is only one exception and rashes and whatnot are specifically mentioned as not being a good enough reason. The only exception is repeated ulcerated skin conditions that will not respond to any other treatment. And I've talked to the CS about this, she has been working at that ins. company for 7 years and has never seen them pay for even a simple pannus.

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