Are there any insurance companies that will cover abdominoplasty ?

Question

It is NOT for cosmetic reasons by the way. It is to close a 3 inch gap in the abdominal rectus muscles withe a severe hernia and was told that major organs are not protected especially my intestines. I am not allowed to get hit, bumped or hopefully if I am in an accident with a seatbelt around my waist.. it would kill me they said. The doc can place his hands between my ab muscles and feel my abdominal aorta and says its extremely dangerous... NO REGULA doctor will close this up unless its a cosmetic surgeon. 5 doctors say the same thing that I am a walking time bomb if i dont get it fixed....but i cant afford the operation. My Insurance co wont cover it because its done by a cosmetic surgeon....General surgeon wont fix it for liability reasons.. not specialized in it. Ughh))) So Im looking for a company that wil cover it. any suggestions? Sorry so long

Answer 1

If you get your doctor(s) to write letters to the insurance company stating that the procedure is medically necessary - including the dangers if it is not done - the insurance company will reconsider.  It sounds like they are seeing "cosmetic surgeon" and reacting without thinking, which insurance companies are very good at doing.

Answer 2

You need to take copies of all the letters from the docs, and appeal again, and send a complaint letter to your state insurance commissioner.

You ALSO need to go ahead and have this done, and worry about how to pay for it later.

It boggles my mind when people have a life threatening situation, but refuse to take the chance to pay for it themselves - they'd rather die, than pay for their own medical care.

Answer 3

Insurance companies are operated by your fellow humans.  It is they who don't care.

Call your state's Department of Insurance and ask for their assistance.  I hope your company gives in.

mbrcatz had no business being critical of you.  That is a poor trait.

Answer 4

Insurance companies see it as elective.  If there is one that does not your doctor would have a better grasp.  But you can not just sign up for insurance and then get an operation.  It is not designed to work that way.

Answer 5

Ok, here is what I found about your problem on Aetna's website, which probably isn't what kind of insurance you have, but it still gives us a general idea of how insurances view your condition. It looks like to me, what you are needing is a "ventral hernia repair", not an abdominoplasty. Insurances see the word "abdominoplasty" and say, nope, that's a cosmetic surgery. So have your dr's remove that word from the papers requesting an appeal. It looks like insurances will cover this as long as its medically necessary and not just for a cosmetic reason. And according to Aetna, they won't cover it just based on the fact that it "might" happen because there is no evidence that having the muscles separated definitely cause a hernia. They won't pay for it if your abdominal muscles have separated and it only looks like a hernia is protruding, but it really isn't a true hernia. Towards the bottom, it says what has to be documented by your dr. in order for them to pay for it such as the size of the hernia, whether or not surgery would be able to reduce it, etc.  I'll just copy and paste all the info below and you can see for yourself. It looks like to me, your insurance will probably pay for it if your doctor uses the right wording. But you need to get them to get "abdominoplasty" off the form. Good luck to you and I hope this helps!

Clinical Policy Bulletin:

Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair

Number: 0211

Policy

Aetna considers panniculectomy medically necessary according to the following criteria:

Panniculus hangs below the level of the pubis; and

The medical records document that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 3 months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 3 months.

Aetna considers panniculectomy cosmetic when these criteria are not met.

Aetna considers panniculectomy experimental and investigational for minimizing the risk of hernia formation or recurrence. There is no adequate evidence that pannus contributes to hernia formation. The primary cause of hernia formation is an abdominal wall defect or weakness, not a pulling effect from a large or redundant pannus.

Aetna considers repair of a true incisional or ventral hernia medically necessary.

Aetna considers repair of a diastasis recti, defined as a thinning out of the anterior abdominal wall fascia, not medically necessary because, according to the clinical literature, it does not represent a "true" hernia and is of no clinical significance.

Aetna considers abdominoplasty, suction lipectomy, or lipoabdominoplasty cosmetic.



Background

In order to distinguish a ventral hernia repair from a purely cosmetic abdominoplasty, Aetna requires documentation of the size of the hernia, whether the ventral hernia is reducible, whether the hernia is accompanied by pain or other symptoms, the extent of diastasis (separation) of rectus abdominus muscles, whether there is a defect (as opposed to mere thinning) of the abdominal fascia, and office notes indicating the presence and size of the fascial defect.

Abdominoplasty, known more commonly as a "tummy tuck," is a surgical procedure to remove excess skin and fat from the middle and lower abdomen and to tighten the muscles of the abdominal wall.  The procedure can  improve cosmesis by reducing the protrusion of the abdomen.  However, abdominoplasty is considered by Aetna to be cosmetic because it is not associated with functional improvements.