Will Insurance Cover My Plastic Surgery After Massive Weight Loss?January 10, 2019
After a long struggle with weight control many people who successfully lose large amounts of weight whether by bariatric surgery, diet and exercise or a combination of both typically correct their medical problems. The long-term problem lies in the fact that where there once was a lot of subcutaneous tissues also known as fat has been depleted. This leads to a large amount of loose skin that can become a challenge in and of itself. This general information may assist you to know about insurance coverage and plastic surgery after massive weight loss.
Plastic Surgery After Massive Weight Loss
The excess skin can make it difficult to find properly fitting clothing, can inhibit certain activities and exercises as well as can lead to rashes and painful skin breakdowns. From a personal standpoint, some people feel the excess skin is still a lot of “fat” and don’t always feel like they achieved their ultimate goal.
The exact number of people that pursue body contouring reconstructive procedures is not known. However, some studies have come up with very small numbers such as only approximately 6% opt for plastic surgery after bariatric surgery. Of those, over 93% have only one procedure.
These numbers, if true, show a severe discrepancy for people that can truly benefit from these procedures. It is also known that the average person who loses a massive amount of weight needs more than one procedure and sometimes upwards as many as five or six. This is due to the fact that the entire body from head to toe has some degree of skin laxity and excess.
One of the major reasons for the large discrepancy in post-bariatric reconstructive procedures is due to cost and insurance coverage. These procedures are typically considered elective in nature and are billed at a cash rate including the surgical facilities and anesthesia.
Most people think (or hope) that their healthcare insurance will cover a portion or all of these procedures. Insurance companies are not in the business to cover any procedures they consider cosmetic. Although there are some blurred lines where the excess skin can cause further medical problems whereby the skin removal could correct this.
Insurance companies have tried to define when they will even consider these elective procedures as functional or restorative. To understand some of the terminology, very generally, a Pannus or Panniculus is defined as the excess skin that hangs over the waist or the pubic area. Anything that’s ends with -ectomy means removal. So a panniculectomy is removing the pannus. Lipectomy is removing fat.
To help with the maze of insurance information, you can review the general information for some insurance plans:
United Healthcare Community Plan (UHC) Coverage Determination Guideline (11/1/2018)
Indications for Coverage
Panniculectomy is considered reconstructive and medically necessary when ALL of the following criteria have been met:
- panniculus hangs at or below symphysis pubis;
- the panniculus is the primary cause of skin conditions when present, such as cellulitis requiring systemic
- antibiotics or transdermal skin ulcerations that require medical treatment;
- there is the presence of a Functional Impairment (interference with activities of daily living) due to the Panniculus;
- the surgery is expected to restore or improve the Functional Impairment.
Note, after significant weight loss, unrelated to bariatric surgery, in addition to the criteria listed above, there must be documentation that a stable weight has been maintained for six months. This often occurs 12-18 months after surgery.
Indications for Non-Coverage
Panniculectomy is NOT considered reconstructive, and is not a covered service, in the following situations (not an all-inclusive list):
- when performed to relieve neck or back pain as there is no evidence that reduction of redundant skin and tissue results in less spinal stress or improved posture/alignment
- when performed in conjunction with abdominal or gynecologic surgery including but not limited to hernia repair, obesity surgery, C-section and hysterectomy unless the member meets the criteria for Panniculectomy as stated above in this document
- when performed post-childbirth in order to return to pre-pregnancy shape
- when performed for intertrigo, a superficial inflammatory response or any other condition that does not meet the criteria above in this document
Documentation may be requested as part of the review, including but not limited to photographs and physician office notes.
Abdominoplasty is NOT considered reconstructive and is not a covered service. Repair of Diastasis Recti is considered a Cosmetic Procedure and is not a covered service.
Lipectomy is NOT considered reconstructive, and is not a covered service, in the following situation (not an all-inclusive list):
- Performed on any site including buttocks, arms, legs, neck, abdomen and medial thigh.
Suction-Assisted Lipectomy of the Trunk
Suction-assisted lipectomy of the trunk (CPT code 15877) is NOT considered reconstructive (unless part of an approved procedure) and is not a covered service.
According to Blue Cross/Blue Shield of California
- Panniculectomy is considered medically necessary for the individual who meets the following criteria:
- The panniculus hangs below the level of the pubis (which is documented in photographs); and
- One of the following:
- there are documented recurrent or chronic rashes, infections, cellulitis, or non-healing ulcers, that do not respond to conventional treatment (for example, dressing changes; topical, oral or systemic antibiotics, corticosteroids or antifungals) for a period of 3 months; or
- there is documented difficulty with ambulation and interference with the activities of daily living;
- Symptoms or functional impairment persists despite significant* weight loss which has been stable for at least 3 months or well-documented attempts at weight loss (medically supervised diet or bariatric surgery) have been unsuccessful; and
- If the individual has had bariatric surgery, he/she is at least 18 months post-operative or has documented stable weight for at least 3 months.
- *Significant weight loss varies based on the individual clinical circumstances and may be documented when the individual:
- Reaches a body mass index (BMI) less than or equal to 30 kg/m2; or
- Has documented at least a 100-pound weight loss; or
- Has achieved a weight loss which is 40% or greater of the excess body weight that was present prior to the individual’s weight loss program or surgical intervention.
- Panniculectomy is considered medically necessary as an adjunct to a medically necessary surgery when needed for exposure in extraordinary circumstances.
Not Medically Necessary
- Panniculectomy is considered not medically necessary when the criteria above are not met.
- Panniculectomy is considered not medically necessary as an adjunct to other medically necessary procedures, including, but not limited to, hysterectomy, or incisional or ventral hernia repair unless the criteria above are met.
- Panniculectomy or abdominoplasty, with or without diastasis recti repair, for the treatment of back pain is considered not medically necessary.
Cosmetic and Not Medically Necessary
- Liposuction is considered cosmetic and not medically necessary for all indications.
- Abdominoplasty, when done to remove excess skin or fat with or without tightening of the underlying muscles, is considered cosmetic and not medically necessary.
- Repair of diastasis recti is considered cosmetic and not medically necessary for all indications.
Brachioplasty is considered medically necessary when done in the presence of significant physical functional impairment (for example, redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, or skin ulcerations) and impairment persists despite optimal medical management (for example, topical or systemic treatments for infection) and the procedure is reasonably expected to improve that significant physical functional impairment.
Brachioplasty is considered cosmetic and not medically necessary when done in the absence of significant physical functional impairment or when not expected to improve a significant physical functional impairment.
Buttock or thigh lifts are considered medically necessary when there is a significant physical functional impairment (for example, redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, or skin ulcerations) and impairment persists despite optimal medical management (for example, topical or systemic treatments for infection) and the procedure is reasonably expected to improve that significant physical functional impairment.
Buttock and thigh lifts are considered cosmetic and not medically necessary when done in the absence of significant physical functional impairment or when not expected to improve a significant physical functional impairment.
Another thing to consider is that to prove “significant functional impairment” it could require years of physician and therapist visits as well as a lot of money for co-pays and out-of-pocket expenses. And even then, it may not get covered.
Just be realistic with yourself. If you truly want a procedure but do not really need it since you may not fit into any of the above categories, it might be more beneficial to go ahead and pay for the skin removal procedure. In the long run, it may cost about the same and will allow you to get on with the things in life that you might want to do or accomplish.
Learn more about insurance and plastic surgery after massive weight loss in my next article, "Is It Mission Impossible For Insurance To Pay For Plastic Surgery After WLS?"
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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