Health Insurance Approving Plastics?

[mistercy]

Okay, 7 months out, and my Dr. says I'll have to go in this spring to repair two hernias. I can get plastics done at the same time.

With the health care exchanges happening, I can choose my insurance for the new year. My wife and I work independently, so we'll pay out of pocket for insurance, but this also gives us a lot choices come January. I might as well use this to my advantage.

Who has gotten their plastics approved by insurance? What insurance was it? I live in NYC, so anyone who lives in the area with recommendations insurance-wise would be appreciated.

What tips do you have for getting plastics paid for by insurance? Thanks for your help, everyone!

[newyorkbitch]

I had no luck. Had a very well documented case, letters of support from other physicians, etc etc. I got turned down, and turned down on appeal.

[sheanie]

I question plastics for you at this point because you are still early out and not yet at goal. It's not recommended to do skin removal/tightening until you are stabilized.

My insurance paid for other surgery, and I had plastics done at the same time. I put the plastics on a Care Credit card and paid that off. My plastics were not covered. My insurance company has never paid for anything I have appealed, and they are getting worse.

Good Luck.

[Deleted]

I was shocked to be approved for a panniculectomy AND breast augmentation (which is apparently actually insurance speak for a breast reduction) along with a hysterectomy about 10 years ago (after my RNY). I was living in Maryland at the time and I didn't wind up having the breast stuff done (waaaaaaay too much at once) but here's the thing. I was NOT approved once I moved back to California and was ready to do it. This was a United Healthcare plan. I think there's a geographic piece to this too... In NY and CA, where plastics are common, many people I've known who have legitimately needed plastics have not gotten approval. No idea whether that's just anecdotal, but I was not expecting approval and got it... in Maryland.

As to how to decipher which plans will be more likely to cover you come January 2014... no clue. Maybe our insurance whizzes will have some thoughts.

[newyorkbitch]

mistercy, if you get plastics in the spring when you are just a year out, you may well need/want plastics again. Ideally, you should wait two years after surgery at least.

[Deleted]

It was about 7 years ago, but Cigna paid for my tummy tuck. The plastic surgeon had lots of experience working on bariatric patients so he did a great job with the medical necessity letter, pictures, etc. I never really had issues, just lots of skin. Nothing was documented prior to going to the plastic surgeon.

I paid for the breast lift done at the same time. Out of pocket expenses for everything (TT and lift) was about $5K. Bad post-op experience but overall very happy with the results.

I had originally gone to a different plastic surgeon (more local to me) and that surgeon did not get anything approved.

[mistercy]

NYB and Sheanie, my docs say I am going to have to get the two hernias done this spring, so if they are going in for the hernias, as long as I am within 40 pounds of goal weight, they are recommending I move forward with the tummy tuck only. The other plastics can wait. Janet, I'll see if Cigna is a NY option - thanks for the tip!

[newyorkbitch]

mistercy, once you pick a plastic surgeon, or as part of the process of picking one, you should talk to the plastic surgeon's office about their experience in getting the tummy tucks covered. You have to demonstrate medical necessity. Are you having medical issues as a result of your pannus now? Such as chronic skin issues underneath it? If so, you need a dermatologist to document it, photograph it, etc. I think you should be prepared to pay the plastic surgeon's fee yourself. The hospital, anesthesia, etc will be covered because of the hernia repairs. Also - you would have to find out the requirements/approval process for your individual policy - there are lots of Cigna plans out there, they vary from plan to plan and from state to state. And someone's experience in the past might not correlate to your approval (or lack thereof) now.

I'm assuming you want a panniculectomy and abdominoplasty.....?

There might be an argument to be made that the muscle wall work could be medically necessary because of the two hernias, which could possibly leave only the panniculectomy to pay for. Discuss that with the surgeon who is going to do the hernias.

Where are you getting all of this done?

[Deleted]

NYB as always is correct

The insurance I had at the time of my TT was company self-insured. The plastic surgeon who did my TT was the one with the experience and knew what he was doing (when it came to insurance). The first surgeon I went to for a consultation submitted to the same insurance company and was immediately denied.

[brooklyngirl]

This might sound like a stupid question to some of you, but I saw it mentioned a few times... Why do plastic surgeons tighten the abdominal muscles with a tummy tuck? Aren't the abs underneath the fat and skin that need to be removed? Are they stretched or different in some way from the weight loss or from being obese? I know I'm going to have a lot of skin to have removed, but I always joked that there was a six pack under there somewhere

[mistercy]

NYB - I've been consulting with Dr. Herron at Mt. Sinai on this one. I don't know if I will get the abdominoplasty paid for, but I am documenting psoriasis under the pannus. Figure it's worth a shot.

[newyorkbitch]

What plastic surgeon is he recommending?

[Deleted]

Nov 13, 2013 21:21:08 GMT -5 brooklyngirl said:

This might sound like a stupid question to some of you, but I saw it mentioned a few times... Why do plastic surgeons tighten the abdominal muscles with a tummy tuck? Aren't the abs underneath the fat and skin that need to be removed? Are they stretched or different in some way from the weight loss or from being obese? I know I'm going to have a lot of skin to have removed, but I always joked that there was a six pack under there somewhere

I did have my abs muscles tightened as part of my TT. Don't know about you, but I never worked out prior to my DS. I guess if you were athletic and had toned ab muscles prior to your DS you wouldn't need them tightened as part of plastics.

I looked at it as a perk to the plastics - don't have to do crunches to tighten my abs

[CVHarris]

I have CIGNA Ppo after my RNY IN 2002 I got a tt. My xhusband got a Tt and breast lift. At that time I also go5 approved for my legs and arms but chickened out. Lol

[CVHarris]

My plastic doctor told me you gain or loose 20 pounds it messes up your tt tightness so make sure you are as close to goal as possible. They paid for my panni because of a hernia and reoccurring yeast under the flap. A hernia 8s the best way to get them to Po ay.

[mistercy]

NYB, I've only met with Herron once so far, will probably meet with him again in January. He only said there is a plastic surgeon he works with regularly on these cases at Mt. Sinai. If you have any recommendations either way, being a fellow NYer, you can PM me, or post here.

[newyorkbitch]

What is the name of that plastic surgeon? Find out sooner rather than later.

Do not use Thomas Sterry.

[Joanne]

Mistercy - Mt Sinai supposedly has a pretty good plastics residency program with reasonable self pay rates, if you need to go that route. Same as at Lenox Hill. I consulted with the one at Lenox Hill and it was very reasonable. I didn't do it there because they would only do one procedure at a time. I had too much I wanted done, and the rates were offset by how much time I would have been out of work for multiple procedures.

If you want a prayer of insurance covering it, document everything. Take pictures, and make sure your complaints are documented by your physician.

[pattyl1]

Nov 13, 2013 21:21:08 GMT -5 brooklyngirl said:

This might sound like a stupid question to some of you, but I saw it mentioned a few times... Why do plastic surgeons tighten the abdominal muscles with a tummy tuck? Aren't the abs underneath the fat and skin that need to be removed? Are they stretched or different in some way from the weight loss or from being obese? I know I'm going to have a lot of skin to have removed, but I always joked that there was a six pack under there somewhere

Many times women who have had children or people in general with a history of yo-yo dieting will have separations in their abs that just aren't supposed to be there. Or some people have all the muscles in the right place but they are too stretched out. Many times as part of a TT they will go in and fix/repair the abs.

I have a hernia and muscle separation. Makes me look like mjy gut is out of proportion to the rest of my body. If I ever found a way to have plastics I would want to have all that fixed.