When would a tummy tuck be medically neccessary? Cosmetic surgery would not be covered by insurance, only if medically needed.
When is Tummy Tuck Medically Neccessary?
Doctor Answers (15)
Tummy tuck, abdominoplasty or panniculectomy
First we need to define some terms. A panniculectomy removes the overhang(sometimes called an "apron") of skin and fat that in some people hangs over the pubic area. A panniculectomy does not tighten up the abdominla muscles nor does it address any loose skin or excess fat of the upper abdominal area.
An abdominoplasty (often called a " tummy tuck") removes excess skin and fat of the entire abdominal area and tightens up the muscles underneath. A panniculecotmy may be covered by some insurance companies while an abdominioplasty or "tummy tuck " is not.
Criteria for coverage of a panniculectomy can vary between insurance companies but most require a history of rashes under the pannus ("apron") which have been unresponsive to treatment with prescription medications by the patients primary care doctor, a history of low back pain and the pannus ("apron") needs to hang below the pubic area.
Tummy tuck and insurance
It has been my experience that the only procedure that insurance will cover is a panniculectomy. That is removal of the overhanging skin and fat from below the belly button. They cover that whn a patient has symptoms of uncontrolled rash and infection and well as hygeine problems. All else is generally considered as cosmetic.
Insurance coverage of tummy tuck (abdominoplasty)
Each insurance plan will vary according to their coverage of procedures. However, most insurance plans will not reimburse for a tummy tuck especially the liposuction component or diastasis repair. In rare instances, instances of severe birth trauma or following massive weight loss with complications of skin breakdown, coverage is provided. Therefore, I would seek evaluation by a physician and have a letter of predetermination of benefits submitted to your insurance carrier. A photograph of skin problems may be supportive of your application.
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Medically Necessary Tummy Tuck
Tummy tucks are rarely, if ever, deemed medically necessary. On very rare occasions, a panniculectomy may be a covered procedure if there is a history of fungal infections, etc. However, this is a very different procedure than a true tummy tuck and most plastic surgeons are unwilling to perform a tummy tuck for panniculectomy reimbursement. Therefore, tummy tucks are almost always paid out-of-pocket by patients.
Tummy Tuck and medical necessity
A tummy tuck is a purely cosmetic operation and would not be considered medically necessary at any time. A panniculectomy, in which only the overhanging skin is removed, is considered medically necessary in massive weight loss patients who develop a rash in the skin fold. Every insurance carrier has its own policy on this so it would be best to check with them if this is your situation. Good luck.
Tummy Tuck is never medically necessary
A tummy tuck is a cosmetic procedure. It involves removing the skin in your lower abdomen and tighening the abdominal muscles. A cosmetic procedure is not covered by insurance. A patient who is having a panniculectomy is sometimes covered after a gastric bypass surgery to remove the skin that is causing rashes or skin breakdown. This does not usually include the tightening of the muscles which most patients need.
Medically necessary Tummy Tuck
The answer to your question depends on the exact description of what the problem is. There are two procedures regarding the abdomen: tummy tuck (abdominoplasty) and panniculectomy.
A tummy tuck is considered cosmetic in nature and is NEVER covered by insurance.
If you have a large, heavy apron of skin which is hanging over your lower abdomen and is causing back pain, infection and irritation, then a panniculectomy is performed. The procedure removes the excess, hanging skin and is considered medically necessary.
Tummy Tuck is NEVER medically necessary
Tummy tuck is a cosmetic procedure.
Panniculectomy (removal of excess skin after large weight loss) can sometimes be covered in extreme cases where the skin is causing repeated infections, cancer, or some other health problem that cannot be managed otherwise.
Tummy tuck and medical necessicity
The answer is never. Tummy tuck is by definition, a cosmetic procedure. Lesser procedures like panniculectomy may be an insurance covered procedure- it includes removal of skin and fat, but no muscle tightening. Still, that would be dicey too, depending on your particular coverage.
Cosmetic Surgery is never covered by health insurance. While insurance companies sometimes call a procedure cosmetic it may be reconstructive. A reconstructive procedure is one where you restore the abnormal to normal, a cosmetic procedure improves on the normal.
If the procedure in question is a tummy tuck you are improving on a normal condition presumable excess skin and far. When the excess skin hangs down and covers the pubic area it is a panniculectomy and sometimes the health insurance companies will cover it. A panniculectomy is a procedure where the skin hanging down below the pubic area is removed , it does not include tailoring of the skin nor relocating the umbilicus, if that is desired by the insurance it is an additional charge.
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.