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 33

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

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.


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!

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.

Insurance coverage for a tummy tuck.

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In my experience, I have never seen a tummy tuck be covered by insurance, for any reason.  Since this is a well-known fact for almost every plastic surgeon I know, they will be unlikely to expand their employees resources in what is almost always a futile attempt.  I don't always agree with an insurance company's decision, but I can assure you that more often than not, the insurance company doesn't care what a doctor thinks.  It is looking for it's bottom-line.

Tummy tuck insurance coverage

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I have never seen a Tummy Tuck or Abdominoplasty procedure being covered by insurance as it's considered cosmetic.  A panniculectomy, which is a very different kind of procedure that addresses excess hanging lower abdominal skin may be covered as a medically necessary procedure with adequate documentation of the size of the pannus, and rash or recurrent infections within the folds.

There is no convincing. Sorry!

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Hi Tech58, Many people are under the false assumption insurance companies will pay for them to have plastic surgery. Many, many moons ago, this would occasionally happened, yes, but healthcare in our country has changed dramatically in the last decade and with the current state of affairs in our government regarding healthcare coverage, I can assure you, no provider is paying for cosmetic procedures. There are patients that have suffered horrific injuries causing life changing scarring and immobility that have to fight for even partial reimbursement for procedures that restore their quality of life. The benefits paid by insurance companies for reconstructive plastic surgery vary greatly from carrier to carrier and plan to plan. If you are hoping that your health insurance will pay for your cosmetic surgery, we recommend checking with them ahead of setting up your consultation. It's not your surgeon's role to help you get your insurance company to do anything. That is between you and them!

Insurance and Tummy Tucks

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Insurance will not cover a tummy tuck as this is deemed cosmetic in nature. They do occasionally cover a panniculectomy which is defined as removing the hanging skin below the belly button that can rub and get in the way of exercise. A panniculectomy is different from a tummy tuck in that there is not internal muscle or fascia tightening and there is no contouring or shaping of the upper part of abdomen above the belly button. There is specific criteria that needs to be met in order for your insurance company to approve a panniculectomy and unfortunately, this differs from one insurance company to another. Consultation with a board certified plastic surgeon is recommended to see what options are available to you. Hope that helps!

-Dr. Angelos

Insurance tummy tuck

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Hi Tech58,

Thank you for your question and attached photo.  Without evaluating you in person, I can't tell you if your excess skin removal would be covered by insurance.  Certainly a formal tummy tuck is not covered by insurance, but removal of excess skin, referred to as a panniculectomy, is covered in certain circumstances.  I would recommend you see a plastic surgeon who takes your insurance to discuss your eligibility.

Hope that helps.

Cheers,

Dr. B

Insurance for a tummy tuck

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Thanks for your question.

Unfortunately, insurance doesn't cover a tummy tuck. Insurance will cover a "panniculectomy" which strictly involves removing the "apron" of skin that overhangs the lower abdomen. A panniculectomy doesn't involve tightening of the abdominal muscles or moving or improving the belly button, which is done in a tummy tuck. 

Best wishes,

Dr. Blagg

Austin, TX

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.