Could I potentially get a Panniculectomy covered by my insurance? (Photo)

Question

I have lost 84 pounds and kept it off since August 2019, currently in May 2020.... the skin fold of my stomach is heavy, causing back pain and makes it harder so do things like going jogging and bending. I get rashes under it from moisture and blackheads constantly as well as sore welts. I am interested in a Panniculectomy do you think I might be a good candidate? I have some scar tissue where I had a drain places when I was sick and that just make me uncomfortable too it sits right on my apron

Kenneth Hughes, MD · Answer

Some insurance companies do not require a specific BMI to cover a panniculectomy.  Instead, they consider medical criteria such as chronic skin rashes, wounds, infections, odor, and other medical issues. Back pain is unlikely to help your case.
The panniculectomy will produce the best results with the lowest risk of complications during and after surgery if you have lost most of your excess weight or your weight loss has stabilized for a period of six months.  You may qualify for weight loss surgery if your BMI is over 35 and you have a serious weight-related health problem, such as high BP, severe sleep apnea, or type 2 diabetes.
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. 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 whether you can have your panniculectomy covered by insurance. Every insurance company is different in their coverage of plastic surgery procedures. In general, however, most insurance companies require that the abdominal apron or pannus completely cover the pubic region. Also, you need to document chronic skin rashes that are refractory to topical creams, lotions, antifungals and antibiotics. Also, you need to be able to document that your abdominal apron or pannus inhibits your activities of daily living, exercise, and even work. Some insurance companies also have criteria regarding significant weight loss. If you lost more than 100+ lbs with diet and exercise, you must be at a stable weight for 6 months. If you lost more than 100+ lbs with weight loss surgery, then your weight must be stable for 18 months. However, it is important to check with your individualized insurance company. Most insurance companies do not cover a panniculectomy solely for back pain.  Thank you for your question regarding the panniculectomy.  I hope that I have answered your questions whether your insurance will cover your panniculectomy.  I specialize in reconstructive plastic surgery after weight loss.  If you have any more questions regarding the panniculectomy, extended lower body lift, lower body lift, 360 circumferential lower body lift, belt lipectomy, belt abdominoplasty, or belt dermolipectomy, please contact my office. Since the panniculectomy or lower body lift is a big procedure, please seek an experienced, board certified plastic surgeon with significant experience performing the panniculectomy or lower body lift. Do your research.  Make sure they have performed at least 100 panniculectomies or circumferential lower body lift 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 lower body lift 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.)

Francis Johns, MD · Answer

Thank you for your question.Insurance companies typically want documentation of rashes that are not responding to treatment, back/neck pain that is treated by PT or chiropractor. Photos have to be taken and also sent to the insurance company. Each insurance company is different on what exactly they are looking for. It is best to be evaluated in person, then they can give you a better idea on what to expect.

Daniel Barrett, MD · Answer

Dear KiShep0629,
if you have a documented history of symptoms caused by your panus, then there is a chance that your insurance will cover the costs of surgery. 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

Robert L. Kraft, MD, FACS · Answer

Occasionally, panniculectomy has been covered. One N.Y. insurer required rashes that were refractory to IV antibiotics.   However, CMS (Medicare) issued a guidance in April that would seem to preclude coverage without advance authorization and, typically, its pronouncements are used by commercial insurers.

Could I potentially get a Panniculectomy covered by my insurance? (Photo)

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Could I potentially get a Panniculectomy covered by my insurance? (Photo)

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