Will amerigroup cover an tummy tuck and breast reduction i am 5'0 even i weigh 174.6 pounds. (photo)

Question

I wear a size 42 D in bras i'm only 5'0 even and i weigh 174.6 pounds i just gave birth 7 weeks ago at the end of my pregnancy i weigh 196 pounds after giving birth i lost 22 pounds

Larry S. Nichter, MD, MS, FACS · Answer

From your description it seems as if you are a good candidate for breast reduction. Unfortunately, each insurance company has their own criteria. 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 through insurance criteria are becoming more and more restrictive. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Emmanuel Mallol Cotes, MD · Answer

Thanks for the question.Generally insurance doesn't cover plastic surgeries. There is an option to make the procedure you want at an affordable cost, so you will not have to incur financial loans.In this regard, you have the possibility of getting a plastic surgery with high quality standards: with Board Certified Plastic Surgeons, in medical centers that follow international standards of patient safety and in comfortable and supervise recovery places after procedure, all for an affordable investment and reasonably lower than the standard values.In that sense I recommend considering coming to the Dominican Republic, its proximity to the US (45min).the "all year summer" and its political and economic stability, as a remarkable development, have made an excellent and safe destination for medical tourism and specially in Plastic Surgery, which it is already a global reference.Finally, i invite you to contact a Board Certified Aesthetic and Reconstructive Plastic Surgeon of the DR.Respectfully,Dr. Emmanuel Mallol Cotes.-

Sugene Kim, MD, FACS · Answer

HI, Dionne34. Congratulations on your recent delivery and weight loss. Tummy tuck is considered to be an elective surgery where excess skin/fat is removed and muscle is repaired.  Insurance company does not cover for the elective, cosmetic procedure.  In regards to breast reduction, depending on your body and your insurance policy, it can be a covered procedure.  Please check with your insurance company to see the inclusion and exclusion criteria for the procedure.  Best wishes.

C. Bob Basu, MD, MPH, FACS · Answer

Every insurance plan has their own unique criteria on whether they will 
cover a breast reduction. More and more, we are seeing plans where a 
breast reduction is not a covered benefit. If it is a covered benefit, 
some insurance plans set a minimum required amount of tissue to be 
remove in order to met their threshold for coverage. Some set the amount
 in relation to your BMI (height and weight). Others require extensive 
medical records documenting neck pain, back pain, and history of rashes.
 The other alternative is to opt for a breast reduction as a self-pay 
option. Start by visiting with a board certified plastic surgeon to 
learn more about your options.Best wishes,Dr. BasuHouston, TX

Fara Movagharnia, DO, FACOS · Answer

Insurance companies will cover a breast reduction as long as you meet their criteria.  Tummy tuck surgeries are not considered medically necessary and are therefore not covered.

Jeffrey Zwiren, MD · Answer

If you meet the criteria then a breast reduction is generally covered by insurance however an abdominoplasty is considered cosmetic and and covered.

Tom J. Pousti, MD · Answer

Thank you for the question and pictures.  Generally speaking, insurance companies do not cover tummy tuck procedures.Best to check directly with your insurance company to see whether breast reduction surgery is a “covered” benefit with your specific policy. Then, given that every insurance company has different “criteria”, best to identify exactly what your specific insurance company considers criteria for approval. Generally, the more documentation you have (for example, from your primary care doctor, physical therapist, chiropractor etc.) the better when it comes to obtaining insurance “authorization” for the procedure. Also, for many insurance companies, the closer you are to your long-term ideal weight, the better.
This documentation and letter/pictures from your plastic surgeon will help you obtain authorization. Keep in mind, as you work towards your goals breast reduction surgery is one of the most patient pleasing operations we perform. Also, prepare to be persistent when dealing with health insurance companies. I hope this, and the attached link, helps. Best wishes.

Will amerigroup cover an tummy tuck and breast reduction i am 5'0 even i weigh 174.6 pounds. (photo)

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