I know for Medicare they dont preauthorize anything and it has to be medically necessary but what I want to know is what do they consider medically necessary for a tummy tuck? I made the mistake of having my hernia repaired in December at my local hospital by a general surgeon instead of going into New York to Columbia Presbyterian to my Bariatric Surgeon. That way I might have been able to combined it with a plastic surgeon in order to atleast have the operating room paid for, the anestesia paid for and then just find out about getting the plastic surgeons fee. I know there is more to it than that but it makes it easier when you combine the 2 surgeries than when you do them seperaretly.
Well, it is too late - I had the hernia done on 12/12/12 and I am recovered from that. I had suffered from that for a year and a half and was in such pain that I just had to get it done. It is really hard for me to get into NYC and my local hospital is across the street from where I live.
So, I at my highest weight I weighed 299, when I went to see my surgeon I was 260 (several years later - Medicare didnt pay for bariatrics when I first started looking) and at the day of surgery I was 249. 14 months later - I hit my goal of 160. I stayed there and l slowly gained a little bit to 168 at my 2 year anniversary when I got really sick. Over the next 3 months, I had 4 open surgeries including bowel obstruction, perforated colon, illiostomy and illiostomy reversal = and I lost 45 pounds during this time bring me down to 123 pounds making me totally immaciated. I was on tube feeds into a g-tube into my remnant stomach - and my incision had to heal from the inside out - 4 times which is how I got the hernia, it never healed.
From 123 = over the past 2 years, with great difficulty and having to eat alot of high calorie foods - against everything I was ever taught - I had to gain my weight back. I am got back to 172 and am now down to 165.
I have tons of loose skin in my lower abdomen - especially on the right side. On my right thigh - there is an area where the skin hangs over even more and it causes the skin underneath to split, crack, bleed and become unbelievably painful - the area can be 1 inch long or it can be 3 inches long but it gets really red but it gets really brite red and bleeds.
I am going to have to start taking pictures. I have been using bactroban ointment to get it heal and to try to avoid infections but it gets bad. I dont know what Medicare's criteria are.
I have Medicare and have been told that all they will cover is a panniculectomy after you have lost the proper amount of weight and maintained for at least a year. However, your thigh is causing this much of a problem, this might just be covered under necessary surgery. You can always ask to have it run through for pre-approval, just like the Bariatric surgery.
Medicare Never preapproves - that is the problem with them. You have meet certain requirements, have the surgery and then pray that when you get your Explaination of benefits a few months later that it is paid. It is a terrible system but that is how they do it. I had that with my Gastric bypass - I had certain requirements that my surgeon and PCP told me that I had to meet and I called Medicare tomake sure what they were and I followed them to a T - then I prayed alot. Yes - they paid for my Gastric bypass 100% but I knew that would be. This I am not sure - it is such a small area - I also have areas of my stomach that hang over but it is only red - not open.
unfortunately I already did the hernia, so it will be a long time before I will be able to afford a procedure in full if every. I really made a mistake by not doing it when I had the hernia done. I was afraid of having the big incision of a tummy tuck, thinking the pain would be so bad, not realizing that the hernia was unbearable so the tummy tuck couldnt have been much worse
Most who get surgery approval have documentation, including pictures, doctor visits, and prescriptions filled to treat the wounds.
Laura in Texas
51 years old; 5'7" tall; HW: 339 (BMI=53); CW: 140 (BMI=22)
RNY: 09-17-08 Dr. Garth Davis
brachioplasty: 12-18-09 Dr. Wainwright; lbl/bl: 06-28-11 Dr. LoMonaco
"If what you're doing doesn't work, change what you're doing - don't complain that it doesn't work."