How can I get insurance to cover a panniculectomy and breast reduction? (photo)

Question

I have been to the dr so many time with back pain and rashes under breast and above my pelvic bone because of sagging breast and saggy abdominal skin. I’m 5’1 and weigh 123 my breast are 36dd and are heavy. I don’t know how to go about asking my insurance company to cover something like this.

Kenneth Hughes, MD · Answer

Some insurance providers will cover the cost of a panniculectomy based upon medical criteria such as chronic skin rashes, wounds, infections, odor, excess skin hanging down below the pubic bone, and other medical issues.   BRs which are medically necessary (i.e. you suffer back, shoulder, and neck "pain" with DOCUMENTED medical attention over a period of a YEAR) are typically covered by most medical insurance providers.  If not, they may try to deny you based upon a lot of things such as lack of symptoms, lack of previous medical management, BMI, and lack of enough tissue that should be removed. The insurance companies will dictate the amount of tissue to be removed, not the PS. 
Read your medical insurance certificate of coverage. Determine what medical information is required for your insurance to issue a pre-authorization or predetermination of benefits for your panniculectomy and breast reduction. Then seek consultation with a board certified plastic surgeon who can evaluate your medical condition, discuss the pros and cons of these surgeries as it applies to you, and help you in completing the paperwork required.

J. Timothy Katzen, MD, FACS · Answer

Thank you for your question regarding how to get insurance to cover your panniculectomy and your breast reduction. In the end, insurance coverage for a panniculectomy and breast reduction depends COMPLETELY on your insurance plan and the benefits you are paying for. I have had many CEOs of companies have their panniculectomy and breast reductions approved because they have excellent insurance. On the other hand, I have had many patients with very poor insurance not have their  panniculectomies and breast reductions covered by insurance. Therefore, insurance coverage really depends on the QUALITY of your insurance, not necessarily your day-to-day skin conditions or the quality of your plastic surgeon’s letter to the insurance company.  In general, the panniculectomy may be covered if you have chronic skin rashes, which are refractory to topical creams antibiotics and antifungals and even steroids. The panniculectomy also may be covered if the pannus completely covers your pubic region. Also, most insurance companies require a stable weight for 6 months if you lost weight through diet and exercise and for 18 months if you lost weight through gastric surgery.  Usually, insurance companies do not cover the panniculectomy if you have low back pain.  Sometimes insurance companies require you to have a BMI of less than 30. The insurance companies almost never covers a tummy tuck, where additional work is necessary to remove even more skin than a panniculectomy.  Also, during a tummy tuck or abdominoplasty, the anterior abdominal wall muscles are repaired with permanent sutures. In regards to your breast reduction, this also depends on the quality of your medical insurance. For breast reductions insurance authorization, you need to document chronic rashes underneath the breasts. Sometimes, documented chronic neck or upper back pain need to be present to achieve insurance coverage for a breast reduction. Thank you for your question regarding how to get insurance coverage for your panniculectomy and breast reduction. I specialize in reconstructive plastic surgery after weight loss.  If you have any more questions regarding the panniculectomy, tummy tuck, extended tummy tuck, high lateral tension tummy tuck, abdominoplasty, lower body lift, 360 circumferential lower body lift, belt lipectomy, belt abdominoplasty, or belt dermolipectomy, please contact my office. Since the panniculectomy or extended tummy tuck are big procedures, please seek an experienced, board certified plastic surgeon with significant experience performing the panniculectomy or extended tummy tuck. Do your research.  Make sure they have performed at least 100 panniculectomies or extended tummy tuck surgeries and have the before and after pictures to prove it.  Carefully examine their before and after pictures and check their reviews on RealSelf.   If you cannot find an experienced, panniculectomy or extended tummy tuck surgeon in your neighborhood, consider traveling out of state if you must. Sincerely, Dr. Katzen. (“Verified” Plastic Surgeon, certified by the American Board of Plastic Surgery, Fellow of the International Society of Aesthetic Plastic Surgery, American College of Surgery, and International College of Surgery and member of the American Society of Plastic Surgery, American Academy of Cosmetic Surgery and RealSelf Hall of Fame.)

Dhaval M. Patel, MD · Answer

Thank you for your question and photo!  I suggest you seek a board certified plastic surgeon and have a physical examination and have the staff submitt your insurance case to insurance agency.  Best of luck!Dr Dhaval Patel
Double Board Certifed 
Plastic Surgeon
Chicago
Hoffman Estates
Oakbrook
Orland Park

Donovan Rosas, MD · Answer

Irregardless of the procedure, the key to insurance coverage is demonstration of medical necessity.Candidates for reduction will typically have documented evidence of neck/back and shoulder pain as well as rashes and bra strap grooving attributable to the increased breast weight. They will often demonstrate that these symptoms have been resistant to more conservative measures like therapy, weight loss and pharmacologic intervention.
In addition to establishing a case for medical necessity, there are also requirements for resection weight (when covered by insurance). This may be a standard "500 gm per side" stipulation or a more variable standard based upon body surface area/Schnur scale. It is important to realize that these weight requirements can occasionally exceed your goals for size reduction. Insurance coverage is contingent on these requirements being met, thus cosmetic concerns become secondary(i.e. cup size goals).With regards to panniculectomy, similarly, the key is demonstrating medical need. In this case, that means intractable rash and skin breakdown secondary to skin apron and overhang. It is also important to remember that this is not a tummy tuck but rather an excision of hanging skin and the degree of resection will be determined by the level of the intertriginous fold/crease. Anything below that crease will be removed, everything above remains.
Based on your photos and narrative, you might be a better candidate for abdominoplasty (which will not be covered).
As always, discuss your concerns with a board certified plastic surgeon (ABPS).
Donovan Rosas MD
Board Certified by the American Board of Plastic Surgery
Member: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons
RealSelf Top 100
RealSelf Hall of Fame

Gerald Minniti, MD, FACS · Answer

Hello,Your appearance does not warrant insurance coverage, regardless of your symptoms. You are not a candidate for a panniculectomy, and your breasts are relatively small for a medical breast reduction.  However, you would get a great result from liposuction and a tummy tuck, as well as a breast reduction, i.e. cosmetic surgery.

Ronald J. Edelson, MD · Answer

You are definitely a good candidate for these procedures but I would not at all surprised if your insurance denies coverage for them.  They are really more in the range of cosmetic procedures.  You can see a plastic surgeon who can try to preauthorize these procedures but I suspect you will be turned down.

Daniel Barrett, MD · Answer

Dear Texasgal830,
in most cases insurance companies cover the cost of surgery if there is a history of complaints. If you are considering a surgery, I would suggest you to consult a board-certified plastic surgeon. Only after a thorough examination you will get more information and recommendations.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Richard J. Wassermann, MD, MPH, FACS · Answer

Based on the photos you shared, it does not appear you would qualify for the Panniculectomy procedure or the Reduction Mammoplasty procedure, but it is always worth a try. Some insurances have different guidelines, but for the Panniculectomy to be approved, there usually needs to be more skin overhang that your pictures show. Many insurances in SC require a fold of skin that hangs below your pubis to even consider the Panniculectomy procedure as medically necessary. Similarly for Reduction surgery, this is often based on your height and weight and something called the Schnur scale. This is a calculation based on height and weight and then states what the minimum number of grams that would need to be removed to qualify as medically necessary. So based on your photos, I would imagine insurance would require approximately 400-600 g/s at a minimum to be removed to qualify as a medically necessary breast reduction. If you removed 400grams from each of your current breasts, it would seem you would be left with less than an A cup. Again, you would need to visit a local Board Certified Plastic Surgeon to get specific information about your desires-Best of luck-

Robert L. Kraft, MD, FACS · Answer

First, go online and read the insurance criteria. Next, find an in network doctor who understands how to deal with the insurer. Panniculectomy coverage is difficult to obtain without intractable rashes that don’t respond to antibiotics. Here in NY, the insurers ask for proof that IV antibiotics failed and they have strict criteria for conservative medical management of macromastia-all designed to prevent women from having important surgeries, thereby saving money-but it is my understanding that coverage is easier to obtain elsewhere in the country. Good luck!

How can I get insurance to cover a panniculectomy and breast reduction? (photo)

Answers (9)

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