How to Convince Insurance Company to Cover Tummy Tuck?

I went to see about a tummy tuck and the doctor said I was a good candidate to have it done. As soon as she heard of my insurance, she said no they do not cover that. With me having hip pain, back pain, unable to do many exercises from excess skin, how does a doctor let my insurance company know it is not just cosmetic. She did not even try to help me get my insurance company to do the surgery. I would like some help in this area.

Doctor Answers 41

Tummy tucks and insurance

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This question of insurance and tummy tucks is a common one.  I see many folks who want to know if an insurer can help cover costs for this procedure.  The short answer is - not fully.  A better way to think about this is to consider two procedures.  One is a panniculectomy, or the removal of the pannus (that's that loose skin of the lower abdomen).  The other is a tummy tuck or an abdominoplasty.

A panniculectomy is like the first part of a tummy tuck.  It does not involve repositioning the belly button and does not involve tightening abdominal muscles.  It is solely the removal of excessive overstretched skin of the abdomen, and some insurers may consider this for coverage.  It often is a concern for folks who have lost lots of weight like after gastric procedures.  There is an insurance code # for this and a doctor can submit a predetermination letter requesting this procedure.  However, this is not a tummy tuck.  Associated symptoms like pain, rashes, etc.,  I have found to be less and less of a concern for insurers.  Some want the loose skin to overhang the pubic area while others want a dramatic effort and history of weight loss.  No matter what they consider, however, the never cover an full tummy tuck surgery because all the codes associated with a cosmetic procedure will identify this surgery as elective and not covered.  There is no getting around this because your insurer will see copies of your medical record and operative report showing exactly what was done.

A tummy tuck would then be a continuation of the panniculectomy where the doctor continues higher. tightens muscles, removes more skin and repositions the belly button.  This obviously take more time and effort.  Insurance companies see this as elective and do not cover this part of surgery.

So, insurance might help to decrease the overall cost of tummy surgery if a panniculectomy is something they will consider.  They will cover the time needed for removal of the pannus.  If however you would rather have the full tummy tuck, which would take more time, you will still be responsible for the time spent of the tummy tuck part of the surgery.  So, in part, the insurance might help decrease the total cost of your procedure.

Hope this helps.

Best Wishes

DEMorales MD


Dallas Plastic Surgeon

Tummy Tucks and Insurance

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Tummy Tucks are typically not covered by insurance. I would suggest that you contact your Human Resources Department to advise you on your benefits. Best wishes!

Christine Sullivan, MD
Columbus Plastic Surgeon
4.5 out of 5 stars 35 reviews

Insurance Coverage for Tummy Tucks and Panniculectomies

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Thank you for your question and for including a photograph for reference.  

In general, insurance companies do not cover tummy tucks or abdominoplasty procedures.  Insurance companies will, however, consider medical coverage for a panniculectomy, or the removal of the excess skin envelope that can hang over the pubic region.  With that said, each insurance company has their own specific set of criteria that must be met in order to determine that the proposed procedure falls within specific guidelines for the procedure to be deemed medically necessary.  

In my practice, my surgical coordinator works closely with the patient and patient's insurance company to file a claim or appeal for medical necessity.  This is sometimes a short and easy process but more often this is a lengthy process that can take several months and sometimes requires several appeals to complete.  Photographs depicting the hanging skin envelope, documentation of medical necessity from primary care physicians and dermatologists, notation as to whether or not the patient has suffered skin infections or rashes as a result of the overhanging skin, documentation of significant weight loss, and sometimes letters from physical therapists attesting to the patients limitations as a result of this excess skin, etc.. will all help to strengthen a patients case for medical necessity.  I hope you find this helpful.


Insurance coverage for tummy tuck

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Insurance companies do not cover tummy tucks, they are cosmetic. They do cover panniculectomy(removal of overhanging skin) when the patient meets the criteria. Each insurance company has their own criteria so you should talk to them first. They will also cover hernia repair but not the tightening of the muscles or repair of diastasis recti. Many plastic surgeons feel it is a waste of time and money for them to check with the insurance company but as the person who is covered by the insurance company you certainly should check.

John P. Stratis, MD
Harrisburg Plastic Surgeon
4.5 out of 5 stars 37 reviews

Insurance

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The insurance companies are always looking not to pay for any procedures. They will cover the cost of a umbilical hernia or other hernia if it is done at the same time as the abdominoplasty. They will not pay for a tummy tuck

Norman Bakshandeh, MD, FACS
New York Plastic Surgeon

Tummy tuck and insurance

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Thank you for your question and for sharing your photo.   A tummy tuck procedure is not often covered by insurance.  A procedure called a panniculectomy which removes the excess skin below the belly button (without addressing the excess skin above the belly button or underlying muscle laxity) can be covered by insurance in certain limited cases.  I have found that this procedure can help with decreasing rashes or infections of the skin fold, but also leaves the patient wishing for the change that is brought about with a traditional tummy tuck (excess skin removal, muscle tightening, liposuction) procedure.  I would visit with a board certified plastic surgeon who can help you discuss your options in more detail.

Does insurance cover a tummy tuck?

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In general, most insurances do not cover abdominoplasty surgery as the overwhelming majority of patients undergoing this procedure are doing so for aesthetic improvement of the abdomen. Patients with heavy overhanging aprons and associated symptoms like you describe may be candidates for something called "panniculectomy," which involves removal of the tissues but no repositioning of the belly button nor tightening of the upper abdomen nor correction of loose muscles. Insurances that cover panniculectomy have stringent criteria that can include rashes under the skin crease, severe back pain not attributable to other causes and not correctable with weight loss or physical therapy, and other considerations. Most plastic surgeons who do a lot of abdominoplasty surgery do not take insurance or do not offer this procedure as an insurance case. In some cases we are asked by patients who clearly do not meet insurance criteria to try to "pass off" the surgery to the insurance, which is fraudulent. Your best bet is to check your insurance's criteria for panniculectomy, then contact plastic surgeons in your network and ask their offices if they offer this procedure through insurance. If you can not find anyone meeting those criteria, you may need to give serious consideration to self-paying for this like the overwhelming majority of other patients.

Tim Sayed, MD, MBA, FACS
Newport Beach Plastic Surgeon
5.0 out of 5 stars 22 reviews

What some insurance companies cover for tummy tuck surgery

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Many insurance companies do not cover any type of tummy contouring surgery unless it is medically necessary. Each company has an explanation of your plan's benefits which you  can for and review. Often companies exclude all tummy contouring surgeries even when a patient has rashes that are resistant to treatment by a dermatologist. Unfortunately, insurance companies don't typically accept patient statements that their back or hips hurt and that they are unable to exercise. Ask your insurance company for your policy's explanation of benefits for tummy tuck surgery and require your insurance company to tell you in writing if it's excluded and what criteria need to be documented to have some coverage. In the past,  insurance companies only covered panniculectomy (excision of hanging skin without any contouring) not tummy tuck surgery(contouring of entire abdomen with excision of excess skin, repositioning of the umbilicus, liposuction of abdomen as needed and recurs plication if needed). Insurance companies continue to exclude procedures, therefore it is critical to get an up to date explanation of your policy's coverage. Good luck

Laurie A. Casas, MD, FACS
Chicago Plastic Surgeon
4.9 out of 5 stars 110 reviews

How to convince insurance company to cover tummy tuck abdominoplasty procedure cost medically necessary

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Thank you for your question regarding medical insurance coverage for a tummy tuck. Every insurance is different. Even within insurance plans, there are different coverage's and restrictions. Usually, most medical insurance plans do not cover tummy tucks. Sometimes they may cover a tummy tuck if you have rashes underneath the pannus. The pannus is the skin that hangs over the pubic region. Other insurance requirements are that the pannus cover the pubic area. The pannus must cover the pubic partially or entirely, but it depends on your insurance. Other criteria that may assist in maximizing your insurance coverage is a history of massive weight-loss or back pain. If you have any of these symptoms, please seek a board certified an experienced plastic surgeon. Also, seek a plastic surgeon that is willing to work with you and your insurance. Most plastic surgeons do not accept insurance. If you have any questions, feel free to contact my office.

Sincerely,

Dr. J. Timothy Katzen

J. Timothy Katzen, MD, FACS
Los Angeles Plastic Surgeon
5.0 out of 5 stars 254 reviews

Frustrating

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We often joke that any patient who says they have "great insurance" has never tried to make a claim. Patients often have complaints such as yours which seem to make a procedure medically necessary. Unfortunately, many insurance companies don't see it that way. Pain can be from a number of sources (hernias, muscular pain, arthritis) and insurance companies are reluctant to pay for anything that might not treat the pain. Good luck. 

Robert Frank, MD
Munster Plastic Surgeon
5.0 out of 5 stars 43 reviews

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.