Would I qualify for insurance to cover my panniculectomy? (photos)

Hello, and thank you for your question regarding whether insurance will cover your panniculectomy. Based on your pictures, your abdominal skin does cover your pubic region, which is a common requirement for many insurance companies when determining coverage for panniculectomy. However, it is important to note that each insurance company has its own set of criteria, and approval is not guaranteed.

Most insurance providers require documentation that the excess skin is causing medical issues, such as rashes, skin infections, chronic moisture buildup, back pain, or difficulty with hygiene. If you have been experiencing any of these issues, it is crucial to document them with your primary care doctor or a dermatologist. Many insurance plans require at least six months of conservative treatment before approving surgery. This treatment may include prescription creams, physical therapy, or weight loss efforts.

Another factor that insurance companies evaluate is stability of weight. Since you have lost 60 pounds and are now stable at 190 pounds, this may work in your favor. Some insurance plans require a minimum period of stable weight (often 6-12 months) before approving panniculectomy.

To maximize your chances of insurance approval, I recommend scheduling a consultation with a board-certified plastic surgeon who has experience with insurance-covered panniculectomies. They can help you navigate the approval process by submitting clinical notes, photographs, and a letter of medical necessity on your behalf. Your surgeon's office may also check your specific insurance policy to determine what is required for coverage.

While insurance coverage is never guaranteed, your case does meet some common requirements based on your description and photos. I strongly encourage you to gather medical documentation, consult with a plastic surgeon, and work with your insurance provider to understand their specific policies.

I hope this helps clarify the process for insurance coverage of a panniculectomy. Best of luck, and I hope you can move forward with a solution that improves your quality of life.

Sincerely,
Dr. J. Timothy Katzen, MD, MBA, FACS, FICS

You will need 360 tummy tuck, with fleur de Lis, muscle repair, I don’t think insurance cover your case.

Here are several steps you need to take to increase the chance of having your panniculectomy covered by your medical insurance if you live in Pennsylvania. It is important to note that a panniculectomy is not the same as a tummy tuck.
If you have undergone significant weight loss, such as after bariatric surgery, you must wait for two years and ensure that your weight has been stable for the past six months.
Contact your medical insurance provider to confirm that there are no exclusions for this procedure. It may be helpful to obtain a copy of your coverage and review it thoroughly, line by line.
Next, you need to establish that the surgery is medically necessary by following these steps:
Have a physician, such as a family doctor (not the surgeon who will perform the surgery), document your skin condition, specifically intertrigo, for a minimum of three months with ongoing medical care and without remission or with recurrence.
Both physicians need to document that your abdominal condition negatively impacts your normal lifestyle and/or job performance.
The physician(s) should document that the excess soft tissue meets specific criteria, such as hanging beyond the pubic area, and provide the necessary photos as required by the insurance company.
You will need to find a physician who is willing to take on your case and check for any special requirements from your medical insurance. This physician should also be willing to communicate with the insurance company to obtain pre-approval. Please note that if you have Medicare, it may be even more challenging to find a physician. Medicare may not provide pre-approval and may consider the procedure as cosmetic, regardless of your condition. The surgeon may only find out after the surgery is performed.
If you successfully fulfill all the aforementioned goals, you will have a chance of having your panniculectomy covered by your medical insurance.
Sean Yuan, MD