Recent Topics
Post Plastics
Karen R. · 2 replies · 43 views
Insurance coverage?
Rianne D. · 5 replies · 72 views
Inner Thigh Lift
TRabbit · 2 replies · 78 views
Most Active

Medicare and Plastic Surgery - anyone covered?

(deactivated member)
on 1/6/11 8:15 pm

Ihave Medicare and Medicaid due to disability from Lupus and Fibromyalgia, complicated by Super MO.  Now that I'm just overweight, my Lupus and Fibro symptoms have improved.  Medications to control flares and pain are now doing what they're supposed to do.

I have at least 20 pounds of hanging skin and uneven random fat deposits, primarily on my lower body.  I have had a couple of bouts of cellulitis, due to frictiion from clothing allowing germs to infect the skin on my legs.

Has anyone ever had Medicare and/or Medicaid cover LBL?  In my case, I would think it would be medically necessary.
birthdaygirl
on 1/7/11 2:34 pm - Lithonia, GA
I have Peachstate here in Georgia which is the health plan I chose for my Medicaid.  They paid for my RNY and they are covering my panniculectomy because it is medically necessary.  They may also be covering my breast reconstruction/lift because of the shoulder, neck and back pain.  It truly feels like I have a 2 bags of rocks dragging from my chest!.....I am from Illinois and I have friends in my profile that are from Illinois that have Medicaid and it paid for their WLS and one of my friends here just had an TT with anchor so I don't know about a full LBL but if you can get all your documentations yourself from the docs you see for pain, rashes, limited mobility because of the excess skin and find a doctor who will accept your Medicare/Medicaid you may get it covered...Some PS may even do extra work as Pro Bono so to speak....also, my sister has Lupus but docs think I may have fibro...do you mind me asking what medicine you take for your fibro and are there any side effects you experience post wls?  i was given some trial medicine from my PCP to try for fibro pain called "Savella"...have u heard of this?
              
HW/293....SW/276....PSW/168....CW/148...GW/150  
(deactivated member)
on 1/7/11 3:11 pm

birthdaygirl-

Never heard of that drug, but I take Cymbalta, which was initially an antidepressant.  The FDA has approved it to also treat fibromyalgia pain and diabetic neuropathy (nerve pain from diabetes).  I also take Lyrica, which you may have seen in TV commercials.  It was also a drug used to treat something other than fibromyalgia, but was found to be effective for fibro.  I have had no ill effects from any of my prescription meds for lupus or fibro, in fact, I was on maximum doses of everything before my DS, and nothing worked except prednisone, a steroid, which also helped push my weight up over 400. 

Now that I've lost weight, I'm on average doses of my meds, and they work the way they're supposed to.  Sometimes, I do get a little drowsy, but not very often, and I have something to counteract that, if I need to take it.  My doctor says the only time I will get prednisone now is if I have a very severe lupus flare, or if an organ  is being compromised by
lupus.

I'm going to find out if my doctor knows of anyone who might want to do a pro bono LBL.  The 3 PS's I've seen have already told me that Medicare won't cover it.  I take that to mean they're just not willing to, or don't have a staff member who knows how to put the time and effort in to get it approved.
ssd1962
on 1/21/11 1:00 pm - Issaquah, WA

Medicare does cover reconstructive surgery after massive weight loss. Here is the link that quotes their pre-requisites chapter and verse:

www.cms.gov/MCD/search.asp.

search term: plastic

I am having a problem with a surgeon who accepts Medicare but doesnt have the first clue about how to bill them. I have a letter of medical necessity explaining how the extra skin poses a threat to my health due to high probability of recurrance gyno issues. Plus a letter of medical recommendation from my GBS surgeon. Plus the surgeon at my first consult had no doubts whatsover I met the Medicare guidelines. I did not choose him b/c I hate their hospital.
Not only did they cancel my pre-op and my op date yesterday (2 days before the pre-op), they have flatly refused all of my referalls to get the info they need from other practices in my area. They claim Medicare hasn't helped them. Medicare helped me and I am the patient, so I know they are full of it. At this point I am down to hunting down procedure codes and other documentation myself. Something I would have done in the first place had I known they did not do their own billing.

(deactivated member)
on 1/21/11 8:53 pm

sd1962 -

I did a cut and paste of the link you gave, but it didn't work.

I went in under www.cms.gov , looked around, and found what might be what I'm looking for.  I did copy this, though and it seems the key is interpretation of one particular phrase:

120 - Cosmetic Surgery

(Rev. 1, 10-01-03)

A3-3160, HO-260.11, B3-2329

Cosmetic surgery or expenses incurred in connection with such surgery is not covered. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member. For example, this exclusion does not apply to surgery in connection with treatment of severe burns or repair of the face following a serious automobile accident, or to surgery for therapeutic purposes which coincidentally also serves some cosmetic purpose.

Did you have something else that specifically says reconstructive or massive weight loss?


ssd1962
on 1/22/11 7:03 am - Issaquah, WA
The link does work. I have used it by typing it in and cut and paste. Make sure when you access the CMS database you enter your correct state and use plastic for the search term.

For the state of WA, under section L22360  there are several paragraphs regarding plastic surgery of all kinds including panniculectomies. The specific language is:

3. Abdominal Lipectomy/Panniculectomy
Abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, such surgery is considered reconstructive. Preoperative photographs may be required to support justification and should be supplied upon request.

The requirements for your state may vary, but probably not by much. According to the CSR I spoke to at length on Friday, the main criteria is "reasonable and medically neccessary".

 The nice thing about Medicare is that you can go anywhere you like for the surgery. I am considering going to CA to have mine simply b/c there are so many more providers.

Hope this helps. Calling Medicare directly helps too.