Will Insurance Pay For My Abdominal Panniculectomy?

Q: Dr. Eppley, I am interested in getting a body lift. I have had bariatric surgery two years ago and I need to get rid of excess skin. This excess skin around my waistline is causing severe chafing. My insurance won’t cover ‘cosmetic’ surgery. My question is this: can we get insurance to cover it if it is a medical necessity?

A: Insurance in some cases will cover an abdominal panniculectomy but it depends if the abdominal pannus meets several criteria established by the insurance industry. for such coverage. The abdominal pannus must of a certain size as seen in multiple view pictures (hangs down onto the upper thighs), have a medically documented history by a physician of skin rashes/infections that failed to be resolved by topical therapies and one must be of appropriate weight based on their height. (within 20% of their ideal body weight) Fulfilling these criteria is what constitutes ‘medically necessary’ and such information must be submitted to the insurance company for them to pass judgment on whether it is covered or not.

Even if determined medically necessary, insurance will only cover the front half of the trunk (abdominal panniculectomy) and to the back half or the full body lift.

Dr. Barry Eppley

Indianapolis, Indiana

Would I Qualify For Insurance Coverage For An Abdominal Panniculectomy?

Q: Dr. Eppley, I honestly need an abdominal panniculectomy and need a price. I do have Medicare and Medicaid. I live in Indiana. How much do they cover and how much would it cost out of pocket. I get rashes and yeast infections because of it. It hangs down to lower pelvic area.

A: There are two options to consider regarding an abdominal panniculectomy. It can be done through my private practice on a self pay basis as an outpatient procedure. This is the most efficient method to have the procedure performed as surgery could be done in matter of weeks at an outpatient facility. All follow up care iss done at one of my private offices. The other route is to use Medicare for the procedure. Medicare is primary over Medicaid so it needs to be approved through Medicare. This would need to be done through my Indiana University practice, meaning you would have to go to downtown Indianapolis to be evaluated, photographs taken and medical records obtained to document the time and number of treatments done to treat the skin infections. To qualify for Medicare coverage the abdominal pannus must be of a certain size (hanging down onto the thighs), rashes must be present underneath it and there must have been a course of at least 3 months of care provided for the skin infections/rash from your doctor. Surgery would have to be done at an Indiana University Health Hospital and all followup care done in downtown Indianapolis. It would take a few months to determine of you qualify.

I would need to see some pictures of your abdominal pannus to determine if Medicare is even an option and I also need some information about your general medical history.

Dr. Barry Eppley

Indianapolis, Indiana

Can An Abdominal Panniculectomy Be Done Without Insurance?

Q: Dr. Eppley, I have been trying to get an abdominal panniculectomy since I lost so much weight. My insurance company denied me but I plan to appeal. I have infections and skin ulcers. It makes it hard to do my job. I heard about the Patriot Plastic Surgery Program and wondered if you can help. PLEASE!!! I wanted to get this done before my husband got home from his latest deployment and I was wanting to get this done before he got home and I’ve run into roadblock after roadblock. Can you help? I have attached some pictures of my abdominal problem.

A: While there is little doubt that you would benefit from an abdominal panniculectomy, I am not surprised that you have been denied by your insurance company. By insurance requirements you do not meet the very basic criteria of the size of the pannus, it must reach down and overlap onto the thighs. Plus there must be a 6 month history of medically documented skin infections that have failed to respond to topical therapies and there must also be current photographic evidence of active skin infections. Failure to meet all of these criteria will result in denial of coverage for an abdominal panniculectomy. This is a very common occurrence and can be difficult to appeal without providing documentation of their established criteria.

The Patriot Plastic Surgery program is where some reduction in fees is offered for a variety of cosmetic surgery procedures, including tummy tuck and abdominal panniculectomy.

Dr. Barry Eppley

Indianapolis, Indiana

Am I A Good Candidate For An Abdominal Panniculectomy?

Q: Dr. Eppley, I have attached some pictures of my stomach pannus. Please let me know if I would be a good candidate for an abdominal panniculectomy. It is the most troubled part of my body. I have backaches and some times irritation underneath due to my jeans. I wear a size16 in pants but that is underneath my pannus. If I got pants to go over my pannus they would not fit my legs and hips properly. I hate this stomach!! :(

A: Thank you for sending your pictures. I do believe you are a good candidate now for an abdominal panniculectomy. The size of overhang of your pannus is significant and much functional improvement would come from its removal. You are not going to have a flat stomach from the procedure, however, and of this you should be aware. It will still be round due to the amount of intra-abdominal fat but there will be no overhang. In preparation for an abdominal panniculectomy, hopefully in the near future, I would still continue to make efforts to lose weight no matter how slight it may be. That will only enable as much stomach tissue to be removed as possible.

Dr. Barry Eppley

Indianapolis, Indiana

Can You Do My High Risk Abdominal Panniculectomy?

Q: Dr. Eppley, I am a 44 year old female. I weigh somewhere between 350 and 370lbs. I have spent many years with multiple medical problems. I currently have Crohn’s Disease, Diabetes (Insulin Pump), Fibromyalgia, Asthma, Underactive Thyroid, Pernicious anemia, CVID and Sleep apnea. Through the years, a strong use of steroids resulted in my right femur breaking. On my first surgery for the femur (Sep 2003), I developed MRSA. I spent the next 4 years constantly having surgeries and receiving vancomycin. In April 2007, the MRSA went dormant. This required removing all hardware from my leg. I currently have a lame right leg. I am wheel chair bound. It was after I permanently moved to a wheelchair that I began to gain weight. I am currently prednisone dependent and I must constantly watch for adrenal crisis. The steroids have greatly added to my weight. Since 2007, my weight has managed to stay around 350 – 360lbs. My skin in so thin and damaged from the steroid use that I have developed an extremely large pannicula. It is very large. On the right side of my body it hangs below the knee. On the left it hangs below the genital area. I develop ulcers in my stomach area. The ulcers often become large, oozy, painful and infected. I have had to take vancomycin to cure the infections. I have a location (at the end on the longest piece of pannicula) that receives inadequate blood flow and it has become hard like a rock. Additionally, I develop fungal infections. I had a C-section in 1999. The fungal infection seems to form on the scar and the infection spreads out. I develop open places along the C-section scar. These places itch and bleed. I am currently treating the fungal infection with a mixture of ketoconazole cream and Diaper rash cream. I also sprinkle a nyoxin powder on the fungal infection. The fungal infection is very difficult to treat. My Infection Disease Doctor and

my Rheumatologist has suggested a Panniculectomy. Each doctor feels that it is important that I receive a Panniculectomy. The doctors said they feel a Panniuclectomy should be performed first and I should look at the gastric sleeve after I have healed. I have been unable to find a Doctor willing to perform this surgery. I know it is a high risk surgery. I am inquiring to find out if anyone in your facility has any experience with this surgery.

A:  Thank you for your inquiry. You are literally between a rock and a hard place. Your needed abdominal panniculectomy procedure is more than just high risk…it is virtually certain to have a 100% complication rate when it comes to wound healing. And that is not to mention your general medical condition which will require considerable after surgery management and is certain to have its own set of complications that could even include severe infection and death. Between the wound and your health complications I could easily see you sending a long time in the hospital. Whomever decides to take on your surgery has to do it with a team approach and be expectant of what is going to ensue. Your best bet is to have this done at a university-based hospital where there is a plastic surgery training program due to the need for a lot of doctors caring for you both during surgery and afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Do I Need A Pubic Lift?

Q: Dr. Eppley, I believe I need a pubic lift. I have lost 100 lbs and am still over weight by a lot. But I had an abscess removed from one side of the upper pubic area and I’m also uneven on both sides. If you type in pubic lift blog on yahoo and under images there is pictures I believe of one you did that is quite large like mine little different I presume. My question is cost and what would be the steps and healing?

A: When

one has lost 100lbs, I would have no doubt that a pubic lift is needed. But I am suspicious that you may need much more than that. Usually such weight loss causes a lot of abdominal tissue overhang which is most commonly

called a pannus or apron. This is a hip to hip removal of the abdominal overhang that would include a pubic lift. It is possible that an isolated pubic lift may suffice, or be partially helpful, but I would have to see pictures of your abdominal area to make a visual evaluation. There is a big difference in the cost and recovery of a pubic lift vs. abdominal panniculectomy so knowing what you look like is essential to answer your questions with any accuracy.

Dr. Barry Eppley

Indianapolis,Indiana

How Long Will It Take To Heal From Having My Abdominal Apron Removed?

Q: Dr. Eppley, I have an “apron” that hangs below my pelvic bone due to 3 c-sections. I have had this for 20 years. It is my dream to wear a wedding dress and not see the hang over through the dress. Would I have time to heal before wedding date of late October 2013?

A: Prepare to have your dream come true. One of the most rewarding of all tummy tucks is the removal of the abdominal apron, also known as a pannus. Its dramatic removal creates not only an instantaneous waistline change but a near lifestyle improvement without a floppy bag of tissue getting in the way of clothes, exercise, personal hygiene and intimate relations. Given that your wedding is over six months away, you will be in good shape for your wedding as long as you have the tummy tuck at least 3 months before the

big day. The other good news is that after the tummy tuck there is no chance that this abdominal apron will ever come back unless one has more children (I am assuming after 3 that you are having no more) or unless you gain a tremendous amount of weight (greater than 50 lbs) and lose it again.

Dr. Barry Eppley

Indianapolis, Indiana

Why Won't Medicare Cover An Abdominal Panniculectomy?

Q: Dr. Eppley, my mother has a grade 5 abdominal pannus that covers her knees and below and 2 years ago developed a lymphedematous mass and hernia through the abdominal wall. It drains fluid off and on chronically and she has been taking antibiotics chronically off and on for years. She is on Medicare and they have denied coverage for the panniculectomy portion of the surgery, stating they will only do the hernia repair and not the panniculectomy which is coming out to 7000 dollars. Is there any advice you can give to help us appeal this? She has been on South Beach diet for 2.5 years, lost 44 pounds on the diet, and been at a stable weight for many years. She can no longer walk due to the herniated pannus. She has atrial fibrillation and a pacemaker and diabetes (although well controlled on oral hypoglycemics) I believe that leaving the pannus in place poses a significant risk to her to develop infection and a clot or other dangerous complications. I would appreciate any advice you can give. We need to fix the hernia and also want the panniculectomy so she can walk again and continue her diet and exercise program as weight loss may also help her atrial fibrillation problem as well. I cannot believe the insurance company considers this cosmetic in a 74 yr old woman. :(

A: It certainly sounds like your mother would benefit greatly by a combined abdominal panniculectomy and hernia repair. But I believe you may have a misconception about how Medicare works. Medicare, a federal program, does not preauthorize or preapprove any surgical procedure. They never have. A surgeon must do the procedure and then wait and see if Medicare will actually approve (pay) for the procedure. When it comes to an abdominal panniculectomy, no matter how medically indicated it might be (and your mother certainly fulfills that criteria), Medicare will almost certainly deny it after it is done. This leaves the patient with the benefit but the doctor will rarely ever get paid and if they do it is pennies on the dollar. An abdominal panniculectomy is a lot of work, risk and after care for little if any reimbursement. A patient may say that this is not their problem but the doctor’s…but it influences the options for many  prospective patients. This is because very few plastic surgeons are willing anymore to do such procedures under Medicare. Thus the origin of the $7,000 fee to which you refer must be a cosmetic fee quote to do the procedure, allowing Medicare to pay for the hospital, operating room and anesthesia fess which they are obligated to do. Short of doing it under this fee for service basis, you will have to seek a plastic surgeon who accepts Medicare coverage.

Dr. Barry Eppley

Indianapolis, Indiana

Do I Need A Tummy Tuck Or A Panniculectomy?

Q: Dr. Eppley, I have had three c-sections, gained and lost over 100 lbs at least three times. ( after each pregnancy) I want to know if I need a tummy tuck or some type of pannus removal.

A: The difference between a tummy tuck and an abdominal panniculectomy is really one of magnitude. They are in many ways the same procedure with some different variations to them. A panniculectomy is nothing more than a ‘big’ tummy tuck. It involves a larger amount of abdominal skin and fat removal as a pannus means an apron or overhang of abdominal tissues across the waistline often onto the pubic areas or upper thighs. Thi

s means the horizontal incision and resultant scar may be longer and even extend into the back area from that of its smaller cousin, the more traditional tummy tuck. Given your description of recurrent weight loss of that magnitude and pregnancies, I would have no doubt that you have a pannus and your surgery would be a panniculectomy, often called an extended tummy tuck. The recovery from a tummy tuck or an abdominal panniculectomy would be the same. Longer incisions do not really mean a longer or more significant recovery.

Dr. Barry Eppley

Indianapolis, Indiana

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Why Won't My Insurance Company Pay For My Abdominal Panniculectomy?

Q: Dr. Eppley, I have been fighting my insurance company since last year due to a yeast infection under the pannus of my stomach. The insurance denied the surgery, saying it was cosmetic, but recently these huge purple marks have appeared and are very thin. A nurse friend said they feel like a blister about to pop and are concave. However, these marks keep spreading across the pannus. My question to you, is, would you, or do you know of a surgeon that would be willing to use me as a teaching subject and take me on as a case study and do the surgery as pro bono? I have had this yeast infection for 7 years and now I am at a standstill. Any advice you could offer would be more then generous. Thank you so much for your time.

A: Battling insurance companies to get coverage for abdominal panniculectomies is standard and the denials and appeals can go on for years. But this is fight you must continue and eventually you should win because you have a real medical necessity condition that justifies an abdominal panniculectomy. It is also a fight you must continue because you are not going to find a plastic surgeon to do it at their own expense. There are also numerous other expenses of surgery (OR, anesthesia, etc) that must be paid that go way beyond whatever a surgeon’s fee is.

Dr. Barry Eppley

Indianapolis, Indiana