I am a 30yr old female who has been morbitly obese most of my adult life. Over the course of the past year I have lost 165lbs (thru diet and exercise-no surgery couldn't get that approved either). I have 30 lbs left to go before I hit my goal weight. I have been working with a surgeon, pcp, and counselor (image issues, mental health) for a few months now. My insurance company (optima) keeps denying me a tummy tuck. Any other suggestions to help win appeal??
Fighting Insurance Company for Tummy Tuck
Doctor Answers 6
Insurance Coverage for Tummy Tuck
They may help cover some of the costs if you meet their criteria. Often this means repeated doctor visits for skin rashes or breakdown. You can learn all about this process on my website under "Patient Resources."
Insurance coverage of tummy tuck
I have not been successful in convincing an insurance company about the validity of the medical necessity for a tummy tuck. However, muscle tightening is not a valid concern for them. Therefore it is best to not bring this up. Generally speaking the skin unlceration and redness my be your best approach.
Fighting insurance company for tummy tuck
We wish you luck in your fight. But the reality is this insurance company, Optima, and MOST others deem cosmetic image surgeon a non covered benefit. That is the way it is. So either start saving or go to a University dept of Plastic Surgery for resident in training surgery at very reduced fees. Best of luck on the last 30 pounds!
From MIAMI DR. B
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Insurance and Tummy Tuck
Your questions touches on MULTIPLE issues.
DOES MEDICAL INSURANCE HAVE TO PAY FOR EVERY TREATMENT ? The answer is - NO. I am not familiar with Optima but I doubt they play differently than the plans we all work and fight with.
Every policy is different and costs vary significantly between "Cadillac" plans and emergency coverage as is provided with Medicaid programs. When you signed with the plan you were provided with a list of conditions and treatments they will partially pay for IF you satisfied their requirements and went through their hoops. Your bariatric surgery was probably NOT on the list and that is why they denied it,
A Tummy Tuck is a Cosmetic NOT a Reconstructive Plastic Surgery procedure and NO insurance pays for it. In many cases, SOME plans may pay for a RELATED tummy operation called a PANNICULECTOMY, or apron resection, in which only the overhang is removed BUT the muscles are not put together, belly button not relocated and excess skin above the belly button is not addressed. THIS operation MAY be paid for IF IT IS LISTED among the list OF COVERED BENEFITS. If it is not on that list, you can argue all you want to, it is contractually absent and they really are not obligated to offer that to you.
This situation will only get worse under ObamaCare where there will be LESS money in the pot and more claims on these resources. The first things to vanish would be anything remotely associated with Plastic Surgery.
I would go over your policy and benefit book very carefully. Read every line. If bariatric benefits or post-bariatric surgery benefits are listed you have a case. If they are not, I think you may not win this one.
Insurance companies will not pay for tummy tucks. Period.
If you are basing your rationale for an abdominoplasty on 'image issues' there is no conceivable way an insurance company will pay for that operation. In fact, the 'code' for abdominoplasty which surgeons have historically used to 'bill' an insurance company for this procedure no longer exists. Save your energy and quit fighting with your insurance company over this issue. Seek out a board certified plastic surgeon that will work with you on procedure pricing. Alternatively, look into the 'resident's clinics' at the local university medical center's (UVA?) plastic surgery training programs. You may be able to get your tummy tuck at a substantial cost savings and have it performed with a team of supervised plastic surgery trainees.
Insurance companies always deny tummy tucks
In your situation, your best option is to apply for a panniculectomy. This procedure is the removal of the hanging apron of skin (pannus) on the front of the abdomen. You will need to document reasons why this is giving you problems and what type of problems you have. You have to strong arm insurance companies to provide coverage for this procedure but it is reasonable to expect them to do it.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.