What to Do for Insurance Coverage for Tummy Tuck and Breast Reduction?

Insurance companies will for practical purposes not cover tummy tuck surgery for "fat getting caught in a zipper" but rather will insist on you losing weight, have recurrent infection or other functional problems.

Re: Your Breasts -Unless 400-500 grams are being removed from at the time of your breast reduction - doubtful for a D cup size, and you have severe documented symptoms from large breasts you will not be covered.

Here is some more information about this

Insurance Criteria for approval for Breast Reduction varies from insurance company to insurance company.  In your case: The more Physician recommendations for breast reduction the better - that would include your gynecologist, primary care doctor, plastic surgeon, chiropractor, etc. They want to see that you have already tried non surgical means such as weight loss, physical therapy, chiropractic treatments, etc but still have problems.. Contact your individual company and request their specific Criteria.
Insurance company favors approval for patient with functional problems like the ones you mentioned - back, neck and knee problems, bad posture, inability to  run , etc.

Your plastic surgeon will then contact your insurance company for preauthorization.
Here is some general information however to help you :Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth).  In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities.  Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month.  Each insurance policy has different guidelines and exclusions.
This procedure is commonly covered by insurance though insurance criteria are becoming more and more restrictive

Thank you for your question.  There are 2 issues at play here.  I'll address the breasts first.  Breast reduction can often be covered by insurance if certain qualifications are met:  neck, back, and/or shoulder pain due to large breasts, bra strap grooving of the shoulders, interference with normal activities of daily living, and possible persistent rashes beneath the breasts, as well as a failure of over the counter pain meds and physical therapy to treat the back discomfort.  These must be documented, typically, by 4 medical practitioners:  plastic surgeon, primary care doctor, physical therapist or chiropractor, and one other (usually ob/gyn).  We also must document that we will remove a certain amount of breast tissue, determined by your height and weight.  With regard to the abdomen, insurance coverage is rarely possible.  Only in the case of massive weight loss - with a resulting abdominal pannus that overhangs the external genitalia, interferes with walking, or is chronically inflamed or infected - can coverage for removal of abdominal tissue be obtained.

Unfortunately, insurance doesn't normally cover procedures for aesthetic purposes. However, you can consider financing, which would allow you to pay just a couple hundred dollars a month for your surgery. Please discuss financing options with your surgeon. Best of luck.

Hello! Thank you for your question! Surgical procedures for aesthetic
purposes, to improve appearance, are not covered by insurance.
Typically, these as well as complications resulting from such procedures
are the responsibility of the patient. Procedures that are meant to
correct functional issues and those which cause health-related issues
should be covered by your insurance as a medical necessity, with proper
examination and documentation.  Some insurance plans have exclusion criteria for certain procedures.  Also, it is an obligation of the surgeon not to attempt to authorize purely cosmetic procedures through insurance.  Having surgery done for depression or body dysmorphia is never a wise decision and you should discuss your issues with your physician/surgeon.Discuss your issues and
complaints with a board-certified plastic surgeon to discuss these as
well as to examine and assist you in deciding which procedure(s) will be
the best for you. A discussion of the advantages and disadvantages will
take place along with the risks and benefits. Insurance companies will
vary on coverage and is always reasonable to discuss your issues with
your surgeon and primary care. It would behoove you to get as much
information as possible and even call your insurance yourself.
Certainly, pay in advance prior to your surgical procedure and options
such as financing are available if you qualify. Hope that this helps!
Best wishes!

Kim,
Many insurance plans will pay for certain operations for body contouring when medically necessary, such as:
1) BREAST REDUCTION
2) PANNICULECTOMY (removal of excess abdominal skin)
3) HERNIA REPAIR
Most PPO, and POS plans and even Medicare will cover some of these operations. However, every insurance company has different requirements before they will cover them. You should check with your insurance company and even consider upgrading to a different insurance company or insurance plan.

Many insurances will not cover a D cup reduction. Others require documentation of conservative medical management including physical therapy. Abdominoplasty is generally not covered without documented medical reasons to support the request. Psychiatric distress has not been grounds for insurance coverage for many years.

As already mentioned, insurance will not cover cosmetic procedures.  As with anything, if you feel that it will help you, I suggest saving up and paying for the procedure.  It may sound expensive (and it may be) but it will have a great beneficial effect on a person.   The rewards are great.

Medicaid IS NOT insurance, as we know it. It is a small selection of ESSENTIAL to your health, hard to obtain, poorly paying medical services which looks like will get worse because of the poor economy and the States' tax money shortage.
A Tummy Tuck (Abdominoplasty) is an extensive cosmetic surgery which involves relocation the belly button, tightening the tummy muscles and removing loose skin. It is never paid for by real insurance company, much less so by Medicaid. In rare cases, some insurance companies and MAYBE Medicaid, will pay for a panniculectomy, the removal of loose skin (WITHOUT anything else). Because of the so-so cosmetic results and the very poor reimbursement, you may have a hard time finding a Plastic surgeon who would do it.
As regards breast Reduction, it really depends on your plan. IF Medicaid rejected you, there is no point in asking them again, in my opinion. You can try however, but after doing it a few times you will realize what surgeons realized a long time ago. They usually win and we lose.
Sorry.

Dear Kim
These are questions I am asked frequently. Unfortunately the answer I will give you will not make you happy.
As far as breast reduction goes you need to show several things. First you have tried non-surgical methods to control your symptoms. And you must have documented symptoms of back pain, neck pain bra strap grooving and intertrigo as documented by your primary care doctor or chiropractor. Then you must be within a "normal weight for your height and finally depending upon your height and weight a certain amount of breast tissue must be removed which could be 500 to 1000 grams per side (about 1 to 2.5 pounds). It is rare for medicaid to approve this surgery.
For the tummy tuck, a cosmetic operation, I have never known them to cover this surgery so I think you are fighting a losing battle on that one.
You might want to try going to the clinic at one of the major teaching hospitals that has a Plastic Surgery Residency and you may be able to be a patient that way.
Sorry if I didn't give you the answer you wanted to hear , but good luck.
Steven Schuster MD FACS

80% of breast reduction questions on RealSelf are about insurance coverage. Here are some helpful points.
1) Insurance companies try very hard not to pay for breast reduction, even though they should. Even small breast reductions relieve many symptoms such as back pain and shoulder pain, and even some types of headaches.
2) Very big reductions (like from an F cup to a C cup) will usually be covered.
3) Many policies will pay for breast reduction if 500 grams (a little more than a pound) or more are removed from each breast.
4) Some policies take your height and weight into account. So that if you are tiny, smaller reductions will be covered. Find out the details of your policy.
5) DON'T get too much of a reduction just to satisfy the insurance company. You will be unhappy with tiny breasts.
6) Your surgeon needs to request pre-certification IN WRITING, and attach as much evidence as possible.
7) Evidence includes letters from your internist, orthopedic surgeon, and/or chiropractor stating that breast reduction will relieve your symptoms.
8) Some companies require that you try "alternative treatments" such as weight loss and physical therapy first.
9) Don't give up. If the first request is denied, demand an appeal.
10) If there is no insurance, and you cannot afford to pay a private surgeon, go to the plastic surgery clinic of a teaching hospital. There, residents do the surgery under supervision, and the cost is minimal. In New York City, we train residents and fellows at Lenox Hill Hospital, and they do good work.