Will OHIP cover liposuction in my back, due to severe back pain? (Photo)

Question

I have Crohn's disease and it's been a battle...weight issues have becoming a frequent issue sending my chronic illness into flares. Finally I have been able to get my life back...but the fat folds have been causing me a lot of pain when I stand and sometimes when I sit making it unbearable. I know they don't consider cosmetic surgery but this is quite painful

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

Jason Emer, MD · Answer

Insurance will not cover cosmetic procedures unless it is causing a morbidity like skin infections or disability.  I suggest making a life change with diet/exercise, nutrition, antiaging physicians/hormone evaluation, and getting the UC/Crons under best control.  Liposuction can help remove some fat and tighten skin, but you may need surgical intervention.  A formal evaluation is needed.  Best, Dr. Emer.

Mathew A. Plant, MD, FRCSC · Answer

Unfortunately not. OHIP will not cover liposuction for pretty much any reason whatsoever. Best of luck!

Kevin O'Grady, MD, FRCSC · Answer

Hello and thanks for the question.No.  OHIP will not cover liposuction for any reason.  Besides, liposuction is not a means of weight loss - it is used to sculpt the body in areas where diet and exercise can no longer make a difference.It sounds like your main issue may be weight gain and it may make your Crohn's worse.  Speak to your GP about this.  A thought may be a referral to a general surgeon for a gastric bypass surgery to help with your weight.  With weight loss, you may not require liposuction.Hope this helps and best of luck!

Mats Hagstrom, MD (license on probation) · Answer

What you describe would be atypical. Insurance companies are reluctant to pay for skin removal procedures. To better understand this, it helps to know that insurance covers medical conditions based on objective criteria. An insurance contract is a legal contract in which the insurance company has an obligation to take care of its members based on certain rules and regulations. A surgical procedure is listed by something called a CPT code. In order for an insurance company to authorize a certain procedure or CPT code, an appropriate diagnosis has to be associated with it. The diagnosis codes form a catalog of medical conditions called the ICD-9 codes. For example, breast reduction surgery is authorized for the diagnosis of neck and back pain and skin infections. There's lots of documented research proving that breast reductions dramatically improve neck and back pain in women who have large breasts. I don't believe there is similar evidence for the removal of back fat.Based on your pictures, it appears you have a substantial amount of skin laxity as well. An in-person consultation might help differentiate what would be the best treatment options and whether insurance can pay for your procedure or not.I will go out to bat for my patients and get insurance authorization if at all possible. At times, this means making multiple phone calls and writing multiple letters on behalf of my patients.Liposuction is not a procedure I have ever received preauthorization for from an insurance company. When dealing with insurance companies, it's important to remember the squeaky wheel gets the grease. Thinking logically, saving all correspondence and being persistent can help. You will also need a plastic surgeon to serve as your patient advocate. Unfortunately, insurance companies pay very little in relation to how much plastic surgeons can potentially earn doing cosmetic surgery. Best of luck,Mats Hagstrom, M.D.

Will OHIP cover liposuction in my back, due to severe back pain? (Photo)

Answers (5)

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