Q: Dr. Eppley, I have lost over 150 pounds and have loose skin in my abdomen however do not have a large pannus flap my skin is just loose and like melted wax which is causing me to have significant vaginal pain and prevents me from doing many activities such as exercise. My insurance says an abdominoplasty can be considered reconstructive rather than cosmetic if a surgeon will submit for medical necessity. I would like to know if you deal with insurance on this type of issue? I am looking at needing other cosmetic procedures as well but right now the pain has made the abdominoplasty a priority because I need to exercise.
A: Getting abdominal surgery covered by insurance is not as simple as the ‘doctor stating it is medically necessary.’ All elective surgeries must go through a predetermination process with a very specific set of criteria that determines whether they would be eligible. The only abdominal procedure that can be approved for health insurance coverage is an abdominal panniculectomy not an abdominoplasty. To get approved for an abdominal panniculectomy there is a very specific set of approval criteria that must be met including: 1)photographic documentation of an abdominal pannus that hangs over the groins and onto the thighs, 2) photographic evidence that the pannus is causing a medical problem (chronic skin infections) and 3) documentation of at least 3 months of non-surgical therapies to treat the dermatitis that has not worked.
If a patient is unable to have an abdominal condition that does not have these three criteria met, a predetermination letter will not be submitted as its denial will be assured.
Dr. Barry Eppley