Is It Mission Impossible For Insurance To Pay For Plastic Surgery After WLS?January 14, 2019
To learn more about navigating the insurance coverage maze, review my "Will Insurance Cover My Plastic Surgery After Massive Weight Loss?" article.
Is it impossible to have insurance to pay for plastic surgery after WLS? For many patients, it can seem as though it is. It helps patients to know and understand the insurance company lingo, CPT Codes, what is and isn't covered, procedures that can be considered as cosmetic, and what you can expect.
Current Procedural Terminology (CPT)
Current Procedural Terminology (CPT) is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. Insurance companies use CPT codes as part of the submission process to determine right away if they can deny coverage.
Common CPT codes for Body Contouring Procedures:
|15830||Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy|
|15832||Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh|
|15833||Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg|
|15834||Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip|
|15835||Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock|
|15836||Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm|
|15837||Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand|
|15838||Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad|
|15839||Excision, excessive skin and subcutaneous tissue (includes lipectomy); other areas|
|15847||Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)|
|15876||Suction-assisted lipectomy; head and neck|
|15877||Suction-assisted lipectomy; trunk|
|15878||Suction-assisted lipectomy; upper extremity|
|15879||Suction-assisted lipectomy; lower extremity|
The other issues that can arise are the number of hoops someone needs to jump through.
Taken from the healthcare.gov website:
Preauthorization is a decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency.
Preauthorization isn’t a promise your health insurance or plan will cover the cost.
This is one of the more confusing aspects of insurance. They ask (or sometimes require) that you submit paperwork to get a pre-approval. However, even if they pre-approve the procedure, they may still not pay for it.
What To Do For Insurance To Pay For Plastic Surgery After WLS
Overall, determining what healthcare insurance will and will not cover is not easy. In my office, we assist all patients by reviewing their medical records and documenting as much as possible. One way patients provide valuable assistance is to get all of your medical records (especially what pertains to your condition) prior to seeing me for a consult.
The other way to help is to get a team to assist. I work with an insurance billing company that is very helpful. As an example of how this works to your advantage is that my office will work together with them to assist with coding, billing, submission etc. For insurance coverage, it can take a village and then some to get surgeries covered. Make sure you choose a plastic surgeon that will work with you in this way.
One more thing to consider is that a lot of times if you are able to show functional improvement after the procedure, there might be a better chance of getting some or all of the procedure covered. Insurance companies have been known to request pre and post-operative photos as well as even personal statements from patients. They also know that patients that have lost a massive amount of weight have a higher chance of complications with body contouring reconstructive procedures. This is also a reason why they may defer approval until completely healed.
Insurance coverage and finances are a large part of the decision-making process when pursuing any medical or surgical procedures. However, settling for less just to have an insurance company cover some of the costs is not always worth it. It is your body that you have worked hard on. Sometimes you get what you pay for.
ABOUT THE AUTHORJaime S. Schwartz MD, FACS, is a highly regarded expert & leader in the field of plastic surgery. Dr. Schwartz is known for his compassion & commitment to safety and advancing the field of plastic surgery through new techniques and procedures. From Dr. Schwartz’ values and relentless “patient-first” commitment, his practice is dedicated to both education and safety. Connect with Dr. Schwartz on Instagram.
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