[Debs]

I'm so sorry to be a pain in the rear...I hope you can help!

When I went to the OH conference there were anumber of plastic surgeons there who recommended getting your insurance company's criteria for approving surgeries as medically necessary, like panniculectomy, tummy tuck, breast lift, etc. I have called my insurance company (blue cross) and they insist that nothing like this exists. Do you know if it does and where I can find it? I'd like to be fully prepared when my surgery request is denied. I'd like to prove to them that I have, say, 4 of the 6 criteria they have listed or however it works.

I think I have discovered that my neck and back pain may be a direct result of lugging around this extra skin. As most do, I have horrible rashes. It is nearly impossible to properly exercise because of the extra skin on my stomach and breasts, not to mention my breasts actually feel bruised most of the time. It hurts!

Thanks for your time and all your help...you've helped me so much already with this ordeal!

[droliver]

Your insurer will have their position on this available somewhere, often online. Below is Blue Cross-Blue Shield of Alabama's related entry (with .pdf link attached) as an example.

"Management of Excessive Skin and Subcutaneous Tissue: Including Abdominoplasty, Panniculectomy, Lipectomy, Thigh, Leg, Hip, Buttock, Arm, Forearm or Hand, Submental Fat Pad or Other Area "

https://www.bcbsal.org/providers/policies/final/058.pdf
"Abdominoplasty, Panniculectomy, and Lipectomy of the abdomen meets Blue Cross and Blue Shield of Alabama’s medical criteria for coverage when all of the following conditions are met:

●

The panniculus folds hang below the level of the pubis
● Clinical records & photos document the presence of symptomatology such as chronic intertrigo, excoriation, infection, back pain, etc., for which 3 months of conservative treatment has been tried
● There is difficulty with the activities of daily living, such as personal hygiene. "

They have made it much harder to meet all the criteria for preapproval for patients & I've talked to one of the higher ups in corporate there who basically confirmed the fact that they do not want to be in the business of post bariatric body procedures PERIOD. The explosion of bariatric surgery procedures was an unanticipated budget buster for 3rd party payors & they've determined that they do not want to get left "holding the bag" for the claims these patients will be making for removing excess skin, etc...

Insurers & medicare have also helped to restrict access as they've gutted reimbursement attached to the insurance code we use to bill this procedure & to this point refused to acknowledge the increase in work many post MWL patients are for their care. Many plastic surgeons will not accept insurance for any of these procedures & you are likely to see that # increase.

[Debs]

Thank you SO very much. This will help. I knew this existed and she was just playing a stalling game with me....it may be different for BC/BS California but this is a start at least.

What I find interesting, as I found it also interesting in trying to get my surgery approved, is that they are SO concerned with money, as they should be. However, in that case, paying for these surgeries is far cheaper in the long run! As we all know, the costs and health risks associated with obesity are far greater than the surgery. My surgery, all told, was about $35,000. I was 33 at the time, 352 lbs and rising. Figuring I'd live to be maybe 60, as heavy as I was, I would have most likely had diabetes, sleep apnea (already had it), arthritis, back pain, skin irritations, heart disease, the list could go on forver. The treatment of those medical issues for the next 30 years is far greater than the $35k they shelled out for my surgery.

Now, basing that same idea onto plastic surgeries---my cash estimate, out the door, for a tummy tuck, breast lift, breast implants and thigh lift was $23,850. That includes surgeon, anethesiologist, surgery center, medication, follow up -- all of it, out the door, just under $24k.

The medical problems I forsee with this extra skin are (1) back pain (2) neck pain (3) severe skin irritations and not to mention (4) the psychological effects of feeling like a repulsive monster. The therapy bills ALONE could be well over $24k over the next 5 years, not to mention treatment for back and neck pain and all the medications for the skin irritations that become infected and could lead to other horrible things (staph infections are not fun, especially with MRSAs).

Maybe I'm just trying to make myself believe it would be better for the insurance company in the long run for my own selfish purposes. Hey, I'll admit it - it's about 10% medical and 90% psychological from my end - I want a flat tummy and perky boobs!

Once again, Dr. Oliver, thank you so very much for this info. It's at least a starting point for me. I'm certain I will again ask for your advice!

[droliver]

FYI: Outside the VA system, Medicare, or countries with universal health coverage arguments for covering procedures because they will save "x" dollars usually fall on deaf ears to insurance companies. That's because most people go though a number of different carriers prior to being medicare eligible & for example: United Healthcare doesn't want to pay money up front for gastric bypass to save Humana money down the road on anti-hypertensive medicines for you.

[Pillows]

I am glad to hear that the estimate for the work done that Debs mentioned was not much higher. That actually seems doable. That is if I get a job...lol.
Janae