Pro’s Perspective on Ruling in Kaiser Plastic Surgery LawsuitSeptember 7, 2015
In recent news, a California judge ruled that Kaiser Foundation cannot routinely deny coverage for skin excess procedures by classifying them as cosmetic in nature. The class action lawsuit, started by Wendy Gallimore of Alameda County in 2012, argued that Kaiser violated California law by refusing to cover procedures designed to remove excessive skin after surgical weight loss. The lawsuit and updates are in the Kaiser Plastic Surgery Class Action Lawsuit (Updated) article.
Understanding the Judge's Ruling on the Kaiser Plastic Surgery Lawsuit
Gallimore argued that Kaiser had violated the 1998 California Legislature statute Health and Safety Code 1367.63. This statute was put into place because insurance companies were denying requests for reconstructive surgery on the basis that it wasn’t medically necessary to restore normal appearance. These denials included deformities caused by trauma, disease and congenital defects. For example, previous to this statute, the insurers were denying cases of cleft lip rhinoplasty repair because the affected children could still breathe through their noses, despite the abnormal appearance. Gallimore argued that insurance companies were violating California law by refusing coverage of reconstructive procedures designed to return the body to ‘normal appearance’ after disfigurement due to disease.
Also included in the 1367.63 statute is the sentence: ‘Nothing in this section shall be construed to require a plan to provide coverage for cosmetic surgery.’ While it is true that insurance companies were denying procedures that should have been covered, it is also true that patients and surgeons have sought coverage for cosmetic surgery by exaggerating functional signs and symptoms. The statute attempted to find a balance between patients, surgeons and insurance companies.
Obesity as a disease and WLS
In 2013, the AMA recognized obesity as a disease. Surgical weight loss is effective and many insurance plans cover the procedures, as they too recognize obesity as a medical condition. The health benefits (and future cost savings to the insurer) of the massive weight loss are substantial as patients see improvement or resolution of diabetes, hypertension, back/knee pain, sleep apnea, etc. With any large amount of weight loss, comes the development of huge amounts of excess skin. The excess skin creates functional problems.
In addition, there is a significant psychological weight to carry (no pun intended) associated with the abnormal appearance. As a plastic surgeon, these patients have come to me for years for abdominoplasties, lower body lifts, thigh lifts, brachioplasties (arms), thoracoplasties (trunk), breast lift and/or augments, face and neck lifts, etc. I have no doubt that many (but not all) of the procedures that I have done on weight-loss patients should be considered reconstructive, based on functional reasons and/or to restore normal appearance, to the extent possible, both of which are criteria for coverage under 1367.63. For the most part, coverage of these procedures has been denied.
"Now insurance companies cannot automatically deny body contouring after
massive weight loss." ~ Dr. Stephen Ronan
The Court has further defined 1367.63 with this case. The insurer will now need to determine if the procedure is considered cosmetic or reconstructive in nature, much as we do for breast reductions (some are covered and some are not based on certain guidelines). It will be interesting going forward to see how patients and insurance companies strike the balance of what will and what will not be covered by insurance with respect to post-surgical weight loss.
Plastic surgery and the WLS process
I did my general and plastic surgery training in a medical center that helped pioneer the gastric bypass procedure. I did a large number of bypasses and was part of the first laproscopic procedure done at our center. Because of my interest in plastic surgery and body contouring, I counseled patients differently from the start. I called the before gastric-bypass patients the ‘before before’, the post-gastric bypass the ‘before’ and my body contouring patients the ‘after’. In my opinion, it doesn’t make sense to consider these patients “done” with their process after the gastric bypass and weight loss. There are huge functional and aesthetic concerns that need to be managed. While massive skin excess is a hassle for patients, we all need to keep in mind that these are good problems to have. The alternative is morbid obesity. Let’s hope that this recent ruling will allow the appropriate patients to get the care they need to complete their process and become a real ‘after.’
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ABOUT THE AUTHORDr. Stephen Ronan is a board certified plastic surgeon based in the Bay Area, California. He served as Chief Surgical House Officer at Columbia Hospitals and Chief Fellow in Plastic Surgery. He founded the Blackhawk Surgery Center where he performs thousands of reconstructive and body contouring surgery procedures annually including abdominoplasties, lower body lifts, thigh lifts, brachioplasties (arms), thoracoplasties (trunk), breast lift and/or augments and face and neck lifts.
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