Would my abdominal scar revision be covered by insurance? (photo)

Question

I recently lost 40lb over a year and I went to an office for a liposuction consolutation and my visit showed that I had very little abdominal fat and it was mostly scar tissue. The skin underneath my scar has fused to the muscle and the doctor told me I would benefit from a abdominal scar revision but the surgery would basically be a tummy tuck. Would the pain of the fused skin make me eligible for insurance coverage? If it only covered partially, what would my out of pocket most likely be?

J. Timothy Katzen, MD, FACS · Answer

Hello. Thank you for your question regarding whether your abdominal scar revision would be covered by insurance. I appreciate your history and photos.

In most cases, it is highly unlikely that insurance will cover a scar revision, especially when it is considered cosmetic. However, if the scar can be documented as the result of trauma or is interfering with daily function, there is a slim possibility that your insurance may provide coverage. Ultimately, it doesn’t come down to the condition itself—it comes down to the quality and policy limitations of your particular health insurance plan. If you pay high premiums for a top-tier insurance policy, there may be a better chance of approval. On the other hand, if you have basic or minimal insurance coverage, it is very unlikely that the scar revision—or especially a full abdominoplasty—would be covered.

That said, you won’t know for sure until you try. I recommend consulting with at least three or four board-certified plastic surgeons who specialize in abdominoplasty and scar revision. Before scheduling your consultations, ask if the surgeon is willing to work with insurance companies and submit prior authorization requests. Most private-practice plastic surgeons do not accept insurance, but some may be willing to help you submit paperwork for pre-authorization.

If you do find a surgeon willing to help with this process, request that they submit a prior authorization letter to your insurance. This letter should include documentation, photos, and ICD-10 and CPT codes relevant to your condition. The insurance company will then review the request and tell you if the procedure will be covered.

If you end up paying out of pocket, the cost for scar revision or a tummy tuck can vary greatly depending on your geographic region, whether the surgery is performed at a hospital or surgery center, and the experience and pricing of your chosen plastic surgeon.

Good luck, and I hope this helps clarify your options.

Sincerely,
Dr. Katzen
(President of the American Society of Bariatric Plastic Surgeons, Certified by the American Board of Plastic Surgery, Fellow of the International Society of Aesthetic Plastic Surgery, American College of Surgeons, International College of Surgeons, and American Board of Metabolic and Bariatric Surgery, and member of the American Society of Plastic Surgeons, American Academy of Cosmetic Surgery, and RealSelf Hall of Fame.)

N. Bill Aydin, MD · Answer

Hi, Thank you for your post. Generally these procedures are not covered under insurance, however, if the scar is painful and it is not just a cosmetic problem it may be covered. I would set up a consultation with your plastic surgeon to see what needs to be done and if they can get the procedure covered.

Marwan R. Khalifeh, MD · Answer

this can go either way, depending on the insurance company.  we provide patients with codes and documentations, but it is up to the patient to speak to the insurance company and try to obtain coverage as we are not in network.  this is not an easy process for most patients, but it is certainly possible with some plans.

Pravin Reddy, MD · Answer

I think it unlikely that insurance will cover the procedure; however, there's no harm in trying.  
Insurance may cover scar revisions if the ciccatrix, or scar, is causing medical problems such as pain.  You may also make the case that the fold of skin associated with the scar is prone to developing rashes.  Finally, you may argue that the scar is unsightly and creating Quality of Life (QoL) issues.
If you choose to submit the case to an insurance company, you will need documentation of the specific problem by your Primary Care Physician (PCP) and documentation that non-surgical treatments failed. For example, if you develop skin rashes associated with the skin folds, then you would have to document the use of steroid and anti-fungal creams. This usually requires months of treatments and it's wise to save all your prescriptions.  
Your PCP will then have to make a referral to an in-network provider for further treatment.  It's a long and tedious process and usually not successful.
I hope this answer helps.

Derby Sang Caputo, MD · Answer

Thank you for your question. It is very important to convince your insurance that this surgery has a medical back ground and not only aesthetically. You will need to do most of the work but it is not impossible. Best of luck

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