Will insurance cover if I have chronic back issues?

Question

I have degenerative disc disease and I get injections in my spine. I’m looking to strengthen my core so I can avoid have neck surgery. I’ve had 2 kids. Also I will be looking into getting a breast reduction. I cannot build muscle in my stomach for nothing. My youngest is 18 and I’ve have tried for years to build it. I have years of proof on my health history and also my spine dr. And primary both agree that this would benefit me and would send in referral's. I’m 160lbs and 5’2

Leila Kasrai, MD, FRCSC · Answer

Generally speaking, a tummy tuck is not covered by insurance. However, you can ask your provider specifically to confirm. If they do, it may be that only the abdominal muscle repair may be covered, since that would probably be the only thing that prevents you from strengthening your core.

J. Timothy Katzen, MD, FACS · Answer

Hello Phenomenal485952, thank you for your question regarding insurance coverage for a tummy tuck due to chronic back issues and degenerative disc disease.

Insurance Coverage for Tummy Tucks
Tummy tucks, or abdominoplasties, are typically considered elective cosmetic procedures and are rarely covered by insurance. Here’s why:

Cosmetic vs. Medical Necessity:
Insurance companies usually distinguish between cosmetic procedures (which are not covered) and medically necessary procedures (which might be covered). A tummy tuck is usually seen as cosmetic because it’s primarily performed to improve appearance by removing excess skin and fat and tightening the abdominal muscles.
Criteria for Medical Necessity:
For a procedure to be covered, it must meet specific medical necessity criteria. Even with your documented history of back issues and recommendations from your spine doctor and primary care physician, it can be challenging to convince insurance companies that a tummy tuck is medically necessary.
Possible Exceptions
In rare cases, insurance may cover part of the procedure if it is linked to other health issues:

Panniculectomy:
If you have a significant overhang of skin (pannus) that causes recurrent skin infections, rashes, or sores, insurance might cover a panniculectomy. This procedure removes the excess skin but does not tighten the muscles or improve the overall contour like a tummy tuck.
Combined Procedures:
If you’re also considering a breast reduction, which can be deemed medically necessary for chronic back pain and posture issues, there might be a possibility of getting partial coverage. However, it’s essential to consult with your surgeon and insurance company about this.
Steps to Take
To increase the chances of insurance coverage:

Documentation:

Gather all medical records documenting your degenerative disc disease, back issues, and any skin-related problems caused by excess abdominal skin. Detailed notes from your spine doctor and primary care physician supporting the procedure’s medical necessity will be crucial.
Pre-authorization:

Your plastic surgeon can submit a pre-authorization request to your insurance company, including all medical documentation and letters of support from your doctors.
Consultation with a Plastic Surgeon:

A thorough consultation with a board-certified plastic surgeon who has experience dealing with insurance companies can provide more insight. They can help you understand what documentation is needed and the likelihood of getting coverage.
Conclusion
While tummy tucks are rarely covered by insurance, especially if deemed primarily cosmetic, there are exceptions. Given your chronic back issues and extensive medical history, it’s worth pursuing the possibility with detailed documentation and support from your healthcare providers.

Good luck with your journey, and I hope this helps clarify your question regarding insurance coverage for a tummy tuck.

Sincerely,

J. Timothy Katzen, MD, FASMBS, FICS
Plastic Surgeon

Camille Cash, MD · Answer

A tummy tuck is a considered a cosmetic procedure and is not covered by insurance.  Some patients are eligible for a panniculectomy under insurance which is removal of an apron of hanging abdominal skin, but this is very different from a tummy tuck.

Gary M. Horndeski, MD · Answer

Insurance companies do not cover tummy tucks but may cover a panniculectomy.  They may also cover a breast reduction, if you meet the weight criteria.

Best Wishes,

Gary Horndeski, M.D.

Scott C. Lindsay, DO · Answer

Hello and thank you for your question.
Contact your insurance company to see if a tummy tuck surgery is covered  under you policy. Keep in mind that many plastic surgeons do not take insurance for this procedure. Schedule a consultation with a board  certified plastic surgeon to discuss your options. Best wishers!

Will insurance cover if I have chronic back issues?

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Will insurance cover if I have chronic back issues?

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