ps

Aug 13, 2009

Post Date: 8/13/09 1:57 pm

I've been on a few threads that went on and on and on about how OHIP doesn't pay for this and doesn't pay for that and from what I heard from surgeons that's just not true. I guess you have to ask the right surgeon and learn the right lingo. I found an awesome post on another board when researching OHIP approval and thought I'd share.


"I am placing this in the TT board because many people from Ontario Canada don't know what to ask for when they go to the PS for a TT consult. There is also mention of breast reduction in this post so if any mod feels like I haven't placed it in the right forum, please feel free to move it as the need may be.
The section on Panniculectomy follows after the section on Breast Reduction...

~THANKS!!!

In the province of Ontario Canada, there are indeed some situations in which PS is covered. One such situation is BREAST REDUCTION.

In order to be considered for a breast reduction on the OHIP plan, you must present with significant symptomatology.
This is some of what OHIP considers significant symptomatology in regards to breast reduction.

Firstly be aware that pitosis (sagging) of the breasts is NOT enough to have OHIP cover your reduction surgery. It should be a contributing factor, but as well there should be documented pain in the shoulder or neck regions, bra strap indentations of the shoulder area, skin fissuring in the creases and folds and intertrigo (rashes) associated with excessive and uncontrollable moisture in the folds and cleavage of the breasts.

If you are experiencing ANY of the above symptomatology, MAKE SURE you take yourself to your regular family doctor or in absence of a family doctor to a walk in clinic and report the symptoms to a medical professional and ask for his/her advice on the best way to deal with them.

One of the things that finally pushed me over the edge to surgery was the fact that a year ago I ended up in the ER thinking that I was having some kind of stroke due to numbness in the arm and face, only to find out that I was healthy as a horse, but the nerve compression in my shoulders from lugging around my huge breasts was the problem. It was embarrassing for about 2 seconds until the cardiologist suggested breast reduction to alleviate the symptoms and actually wrote it in her discharge notes for OHIP.

One thing my PS told me is that if you are over a D cup in Ontario the chances are good that you will be approved; having the other symptomatology is like the icing on the cake. So if you are over a D cup, with strap indentations, the chances are good that OHIP will eventually approve your request.

Another situation that may be covered by the OHIP plan is PANNICULECTOMY.

It is important that you know your terminology when you enter into a consult with a plastic surgeon. If you go in asking for a tummy tuck consult that is exactly what you are going to get a cosmetic tummy tuck consultation.

If you go in asking for an OHIP insured panniculectomy consult then that is what you are going to get.

MAKE SURE that you are refferred to your plastic surgeon through your family doctor and that the plastic surgeon works out of a provincially funded hospital. OHIP WILL NOTcover surgeries done in private surgical centers for ANY reason. The surgery and aftercare MUST be in a provincially funded and regulated hospital in order for coverage to be considered.

In researching the procedure it is easy to become confused because the term abdominoplasty and panniculectomy are quite often interchangeable when you are searching online.

In a lot of cases and with a lot of insurance companies they carry the exact same billing code therefore making it very difficult for the companies to determine exactly what procedure you are asking for. Since OHIP never covers a cosmetic tummy tuck, the proper term is panniculectomy for insurance purposes.

Once again, symptomatology is KEY when asking for OHIP to cover a panniculectomy. Rashes, skin fissures, back pain, lower body pain restricted movement, all of these fall under symptomatology for panniculectomy. It is paramount that your symptomatology be recorded.

Do not be ashamed or fearful in going to a general practitioner (family doctor) and asking for ways to manage pain brought on by the weight of the pannus. Don’t be afraid to go week after week, month after month or for every rash, odor or anything “abnormal” all of these visits are recorded and then OHIP has a basis in which to judge your claim.

What is an OHIP insured panniculectomy? The definition of panniculectomy says that it’s the excision of redundant fat and skin below the navel for functional purposes sometimes with and sometimes without preservation of the umbilicus (belly button.)

When I went for my consult I was fully expecting to hear that there would be no muscle repair involved and that I basically would get what I got on the other side of surgery, but that is not what I heard from my PS, instead I heard that there will lipo around my rib cage and there will be a hip to hip incision, and in some cases an inverted T from the belly button to the pubic mound (this will be the case for me as I have an extra paunch there that needs extra work to deal with) there will be placation of the fascia (tightening of the abdominal muscles) and there will be repositioning of the umbilicus ( belly button)….

Now if that doesn’t scream TUMMY TUCK, I don’t know what does. It’s not in what you say to OHIP, but how you say it that makes all the difference.

I was also informed by my PS that OHIP has a habit of denying at least 50% of requests for panniculectomy and they basically do it to see who is serious enough to fight with them over it, so if you receive a denial don’t think it’s the end of the world; it’s just OHIP saying “convince me.”

I was lucky and got my approvals without having to appeal, but when dealing with provincial health insurance remember that it’s not personal, it is their job to make sure that you know what it is you are doing, that you meet the criteria for them to fund the operation and that you are serious about your health and the maintenance of it post operatively.

I have read what I think might be a million messages all over the internet by people saying that OHIP doesn’t cover a TUMMY TUCK… this is true, they don’t cover a TUMMY TUCK because TUMMY TUCKS are believed to be strictly cosmetic, what they do cover is PANNICULECTOMY that is considered medically necessary and reconstructive and if you have all your ducks in a row you should have no problem getting one."

LeahFlameRain Posted: Thu Mar 20, 2008 4:56 am    Post subject: Dealing with OHIP - The Ontario Health Insurance Plan

http://messageboards.makemeheal.com/viewtopic.php?t=77491&sid=4736a81f8ebc77205661d1c1eba7...

Just thought this would be some useful information for some. Please no flaming. Take it for what you will. This is what I found doing my own search and thought it could be useful.

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