Question:
Blue Cross Blue Sheild HMO, criteria for Tummy tuck??
Hi, I am 7 months post op and I am with in 18 lbs of goal, surgeon said it was ok to persue a tummy tuck and gave me the Plastic Surgeon who works with my insurance I am just wondering what the criteria is to qualify and what i can do to "help" with that. I have an apron that I really want taken care of as well as possibly a breast lift. The PS Surgeon is Dr. Hoyt in Modesto, MY GB surgeon was Dr. Coirin and I LO)VE him. Any help is greatly appreciated. — britiiiz1 (posted on June 16, 2006)
June 16, 2006
I didn't see a profile, so I am shooting in the dark. I know of a Modesto
in California, but that is the onlt state where Blue Cross and Blue Shield
are seperate. Here is the Blue Cross of CA criteria:
Medically Necessary:
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
The individual has had significant weight loss of 100 pounds or more, as
well as the following:
the individual has maintained a stable weight for at least six months AND
if the individual has had bariatric surgery, he/she is at least 18 months
post operative; AND
One of the following:
there are recurrent or chronic rashes, infections, cellulitis, or
non-healing ulcers, that do not respond to conventional treatment for a
period of 3 months; information must be documented in office visit records;
OR
there is difficulty with ambulation and interference with the activities of
daily living; information must be documented in office visit records.
Panniculectomy is considered medically necessary as an adjunct to a
medically necessary surgery when needed for exposure in extraordinary
circumstances.
Per the criteria, you have 11 months to wait. Best of luck!
— nursenut
June 17, 2006
Hi Wendi, the info the previous post gave isn't necessarily the way all
insurance companies and/or doctor's look at things. I live in Vacaville
and have a plastic surgeon my pcp referred me to. I am out about the same
as you...7 months and have 18 lbs to goal also (funny huh! I have lost
-117lbs so far) I have preliminary authorization for a breast reduction
and my pcp said for me to ask the ps about a tummy tuck to be done at the
same time. The ps I just saw in Sacto was so much better than the one I
saw in SF... you can read on my profile. I have been in extreme pain from
my large breasts and have problems with redness, rash, etc. Like you, my
extra skin under my tummy is causing problems also. Feel free to email me
direct. My insurance company, pcp, surgeon who referred me (I have
wha/sutter health, so I needed to be referred from pcp/surgeon within the
system before going to ps) and the plastic surgeon all agree, we don't have
to wait for a year to pass, etc... the things people post about ps after
wls.... so go for it... do what you need to do, starting with your
pcp...document everything and take PICS!!!! I have pics documented from
the very beginning of my struggles. Good luck! I look forward to hearing
from you.... p.s. are you coming to the OH Conference next week in
Fairfield????
— GypsyWoman
June 17, 2006
Wendi,
I think the first person who replied had the best advice, especially since
they had checked out YOUR insurance companies qualifications. Also you
should call the insurance company yourself and get them in writing so that
you know what your chances are for insurance approval, all PS will work
with insurance if there is a chance that insurance will pay. Obviously
you need a documented history of rashes and infections that aren't cured
with medications etc.. Medical necessity is important otherwise the tummy
tuck is considered cosmetic and not necessary and insurance wont pay. Be
prepared to follow the insurance company's guidelines to the letter and
jump through all hoops if you expect them to pay.
Good Luck
— goldroses
June 17, 2006
I am really surprised. My surgeon's wife if an excellent plastic surgeon,
and she and my weight loss surgeon tell you to wait eighteen months to two
years before even considering it, because your body needs to adjust and
your weight needs to level off.
— blm4602
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