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.