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TOPIC: Insurance to pay for Tummy Tuck??

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September 5, 2012 7:20 PM
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! :)
  19861998
September 5, 2012 7:23 PM
bump because I am curious!
September 5, 2012 7:28 PM
Gahhhhhhh..
Well, I need more answers than this lol
  19861998
September 5, 2012 7:32 PM
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.
  13382740
September 5, 2012 7:37 PM
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.
September 5, 2012 8:28 PM
QUOTE:

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?
  19861998
September 5, 2012 8:30 PM
QUOTE:

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 wink
  19861998
September 5, 2012 8:45 PM
Bump please :) Need more answers lol
  19861998
September 5, 2012 8:49 PM
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.
  28683338
September 5, 2012 9:25 PM
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.
September 6, 2012 5:54 AM
Thanks guys :) Helpful info!
  19861998
September 6, 2012 6:05 AM
Very informative and interesting topic - thank you!!
  25932784
September 6, 2012 8:14 PM
QUOTE:

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..
Edited by ExplorinLauren On September 6, 2012 8:25 PM
  19861998
September 6, 2012 8:24 PM
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!
  19861998
September 11, 2012 6:21 AM
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.
  26854075
September 11, 2012 6:58 AM
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.
Edited by omma_to_3 On September 11, 2012 6:59 AM
  7246266
September 11, 2012 7:02 AM
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!
  1976963
September 11, 2012 7:02 AM
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)
September 11, 2012 7:02 AM
bump
  19998837
September 11, 2012 7:03 AM
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.
  6214796
September 11, 2012 7:03 AM
QUOTE:

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!
  4001156
September 11, 2012 7:03 AM
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!
  11871130
September 11, 2012 7:04 AM
Im in canada, mine will be covered, because its caused from having twins. I also have a hernia and a lot of muscle seperation.
  8151434
September 11, 2012 7:06 AM
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?
  143739
September 11, 2012 7:07 AM
QUOTE:

QUOTE:

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.

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