How can I get approved for a panniculectomy with muscle repair?

Question

I’m a 5’0”, Hispanic, 40 year old woman who has had 2 c-sections l. Second cesarean opened in one side a couple weeks after giving birth in 2014. I had a VSG in November of 2022 and my highest weight was 252. I am 194-197 and am going to start Ozempic to lose 20 more pounds. The sides of my cesarean scars hurt now that my tummy hangs. How can I get a panni WITH muscle repair approved? What are the steps I can take? Is it possible?

J. Timothy Katzen, MD, FACS · Answer

Thank you for your question. Based on your description, it seems like you are seeking a tummy tuck rather than just a panniculectomy. A panniculectomy removes excess skin from the lower abdomen (the "apron"), while a tummy tuck (abdominoplasty) also includes muscle repair to address abdominal separation (diastasis recti) and improve the contour of your entire abdomen.

Unfortunately, most insurance companies do not cover muscle repair because it’s considered cosmetic rather than medically necessary. However, a panniculectomy might be covered by insurance if you can demonstrate medical necessity. Here's how you can increase your chances of getting a panniculectomy covered:

Document Medical Issues: Work closely with your primary care physician or surgeon to document any medical issues caused by your overhanging skin, such as:

Chronic rashes or infections under the skin folds.
Pain or discomfort that affects your mobility or daily activities.
Difficulty with hygiene or skin breakdown.
Photographic Evidence: You’ll likely need to submit photos of your hanging skin to your insurance company, along with documentation of your medical symptoms.

Conservative Treatments: Show that you've tried non-surgical methods to address your symptoms, such as creams for rashes, special garments, or physical therapy.

Letter of Medical Necessity: Have your doctor write a letter to your insurance provider stating that the panniculectomy is medically necessary to alleviate health issues caused by the excess skin.

As for muscle repair, it’s usually not covered by insurance. However, some plastic surgeons offer the option to combine a panniculectomy with a tummy tuck, where insurance covers the panniculectomy portion, and you can pay the difference for the additional muscle repair and aesthetic improvements. It’s worth discussing this option with a board-certified plastic surgeon.

I hope this helps guide you through the process, and good luck with your weight loss journey!

Sincerely,
Dr. Katzen

Camille Cash, MD · Answer

From your description it sounds like you are more looking for a tummy tuck.  This is considered a cosmetic procedure and is not covered by insurance.  You can contact your insurance company to inquire about coverage for the panniculectomy and the criteria for approval.

Azita Madjidi, MD, MS, FACS · Answer

Panniculectomy does not include muscle repair. You can document all of the infection or irritation caused by your hanging skin by a dermatologist or your primary care physician. You can go on your insurance plan's website and search for panniculectomy and see what the criteria are for coverage. In general, your pannus has to hang below your pubis down to mid thigh and cause recurrent infections to justify medical necessity. 
Muscle repair is part of abdominoplasty which is a cosmetic procedure.

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How can I get approved for a panniculectomy with muscle repair?

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