One of the most common questions asked by patients during an initial consultation is “Will insurance cover my surgery? “ There is a common misconception that plastic surgery is not usually covered by insurance and patients will have to pay out-of-pocket for surgical procedures.
Depending on the situation, people are very surprised to learn that insurance will cover certain procedures. This largely depends on if the procedure is considered cosmetic or reconstructive/medically necessary. In some instances, such as breast reconstruction, it is mandated by federal law that reconstructive procedures to be covered by insurance. This was discussed in detail in my prior blog on breast reconstruction. (https://monmouthhealthandwellness.com/october-17th-is-breast-reconstruction-awareness-day/) In addition to breast reconstruction there are other procedures that health insurance companies may consider reconstructive and are covered as part of plan benefits. It is important to understand that many insurance companies tend to follow the guidelines set by the Centers for Medicare and Medicaid services most commonly referred to as CMS. (Https://www.cms.gov) CMS is an agency of the federal government that sets Medicare and Medicaid policy in the United States. In this article I will discuss some breast and body procedures that commonly covered by insurance.
Breast reduction, sometimes referred to as reduction mammaplasty is a surgical procedure that is performed to correct macromastia which is the medical term for enlarged breasts. During breast reduction surgery, the breasts are reduced in size and are reshaped to improve appearance. Reduction mammaplasty is performed for cosmetic as well as for functional purposes.
In order for breast reduction to be a medical necessity, certain conditions must be met. First of all, one must have symptoms secondary to the enlarged breasts such as back and neck pain, grooving from the bra straps, skin rashes underneath the breast folds which is called intertrigo. These rashes are usually worse during the summer months. In addition to these symptoms, anyone over the age of 35 needs to have a full breast evaluation which includes a mammogram, before being considered for breast reduction surgery. This evaluation is generally performed by a board-certified plastic surgeon, general surgeon, breast oncologic surgeon or gynecologist. Once the breast evaluation is completed, it must also be demonstrated that the cause of macromastia is not related to a medical condition such as certain medications that may cause the size of the breasts to increase or hormonal imbalances which are commonly referred to as endocrine or metabolic disorders. This evaluation is generally performed by a primary care physician such as an internist, family physician or gynecologist. Once these evaluations are completed, it must also be demonstrated and reasonable that non-surgical steps have been taken to reduce the burden of symptoms secondary to macromastia. This generally involves, weight loss, evaluation by an orthopedic surgeon, evaluation by a dermatologist, conservative use of pain medication, use of support garments and physical therapy or treatment by a chiropractor. If symptoms persist despite all of these interventions, and there is documentation of a failure of all of these non-surgical methods, only then will insurance consider a breast reduction medically necessary.
Male Breast Reduction:
Enlarged breasts in males is a condition called gynecomastia. Gynecomastia surgery involves removing excess breast tissue in males. CMS considers gynecomastia surgery medically necessary in males who have a moderate enlargement of breast tissue and/or excess skin which causes the breast to appear feminized. As with female breast reduction, medical, hormonal, medication or drug related causes of this must first be ruled out by a primary care physician or an endocrinologist prior to be considered for surgery.
Surgery to Remove Excess Skin After Massive Weight Loss:
Due to the tremendous success of people losing weight either through diet and exercise or weight loss surgery, individuals often seek to remove excess skin. Unfortunately for some after massive weight-loss, the excess skin does not shrink. This is due to the fact that skin has lost its elasticity and remains stretched out even after someone has done a fantastic job of losing weight. The most common area that patients usually complain of excess skin is in the abdomen. There are also guidelines from CMS on when excess skin removal is considered medically necessary. Excess abdominal skin removal following weight loss is commonly referred to as a panniculectomy. A panniculectomy is a surgical procedure that is performed under anesthesia to remove excess skin and fat from the abdomen. A panniculectomy is slightly different from an abdominoplasty which is a procedure is commonly referred to as a “tummy tuck.” During a panniculectomy excess skin and fat is removed from below the umbilicus (belly button). An abdominoplasty is considered a cosmetic operation where excess skin and fat are removed along with tightening of the rectus abdominis (6 pack muscles) and repositioning the umbilicus in a more aesthetically pleasing position; this is generally considered a cosmetic procedure.
In order for a panniculectomy to be considered medically necessary, several criteria have to be met. The first of which is that the excess skin is secondary to massive weight loss after weight loss surgery such as a sleeve gastrectomy, gastric bypass or gastric band. The patient must be 24 months post-operative from these procedures to be considered for panniculectomy. In addition, the patient must also be suffering from skin rashes in the abdominal folds that have not improved after topical treatment for at least three months as prescribed by a dermatologist. The excess skin must also be so severe that it is hanging below the level of the pubic bone. Another important criteria is that the patient’s weight must be stable for at least 6 months. Unless all of these conditions have been met and documented, a panniculectomy will not be covered by insurance.
Other areas of excess skin that result from massive weight loss are the arms and thighs. Removal of excess skin in these areas is not considered medically necessary.
Are all insurances the same?
Unfortunately, all insurance plans are not created equal. CMS guidelines listed above are subject to change periodically. Although most private insurance companies generally follow these guidelines, some insurance companies have their own guidelines that may or may not follow CMS criteria. In addition, some insurance companies have plan exclusions meaning that even if all the criteria to be considered a surgery medically necessary are met; under no circumstances will the plan cover it. In other cases, certain insurance plans may have criteria that are not as strict as CMS criteria. For example, certain insurance plans will approve a panniculectomy after 18 months following bariatric surgery instead of 24 months.
Can a surgery be partially covered by insurance?
Yes! Sometimes, surgery can be partially covered by insurance. A perfect example of this is surgery after weight loss where removing the excess skin and fat is covered by insurance, however tightening the muscles and re-positioning of the umbilicus is not covered by insurance. In these cases, part of the surgery may be able to get insurance coverage and part of the surgery will be considered cosmetic and there will be an out-of-pocket expense.
How Do I make heads or tails out of all of this?!?
Understandably, figuring out all of this can be very confusing and frustrating. The only way to determine if your particular procedure will be covered by insurance or if it will be considered cosmetic is to come in to the office for a consultation. One must be properly examined as every case is different and then based on the physical examination as well as the particulars of the insurance plan, it will be determined if the surgery is considered cosmetic or medically necessary. Without an in-person evaluation it is impossible to determine this and cannot be done over the phone. To schedule your consultation please reach out to our office at 732-282-0002 or via e-mail firstname.lastname@example.org.