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Key iconKey Points

  • Insurance coverage for post-bariatric surgery is limited and is generally growing tighter
  • By taking specific measures, physicians can help patients navigate their insurance, including documenting a history of related problems

Dr. Oliver
As the number of bariatric procedures performed in the United States has grown, so has post-bariatric patients' desire for cosmetic surgery to correct its aftereffects, experts say. However, they tell Cosmetic Surgery Times , insurance coverage for these procedures is limited and generally growing tighter.

'BLINDSIDED' When the gastric bypass explosion occurred following the late 1990's advent of laparoscopic techniques, "The insurers didn't see it coming. The expenses to their companies blindsided them," says Rob Oliver, Jr., M.D., a Birmingham, Ala.-based plastic surgeon board-certified in general surgery. As a result, he says carriers are "determined not to let that happen again" when bariatric patients later seek coverage for cosmetic revisions. Accordingly, he says carriers typically might cover only post-bariatric abdominal panniculectomies — if any post-bariatric procedures at all. "Insurers almost universally consider procedures for the arms, thighs, face and everything else cosmetic. And with the abdominal surgeries, their criteria — and how they enforce them — have gotten dramatically more rigid in the last two or three years," to the point where only about one of six patients he sees truly qualifies, Dr. Oliver states.

Dr. Kluska
PICTURE WORTH 1,000 WORDS To help patients navigate their insurance, Dr. Oliver first recommends making sure their policies don't specifically exclude massive weight loss (MWL)-related surgeries. If a patient wants abdominal surgery to be covered, he adds, "Usually they must have some history of related problems — such as yeast infections and chronic active panniculitis — that has been well documented by their primary care doctor," not their cosmetic surgeon. Specifically, patients must have a pannus that hangs well below their pubic bone onto the mid-thigh, says Dr. Oliver, "And it must be visually impressive to get it easily approved." Insurers furthermore tend to require documentation of treatment-resistant panniculitis symptoms persisting at least three to six months, adds Michael S. Wong, M.D., assistant professor, Division of Plastic Surgery, and director, Body Contouring after Weight Loss, University of California Davis Medical Center. "Some might consider that strict," he says, "but if one knows about it ahead of time, it's no surprise." Dr. Wong adds, "Another reason one might get a panniculectomy covered is if it's so big it hangs between a patient's thighs, causing difficulty in ambulation." Similarly, says Michael S. Kluska, D.O., a dual board-certified plastic and reconstructive surgeon and general surgeon in private practice in Greensburg, Pa, "I dictate a letter to the insurance company documenting the problems these patients are having," including chronic irritation and hygiene issues caused by the overhang of skin. "I also document with photography the irritation they have underneath that fold," he says. If one documents these problems well, Dr. Kluska says, "Usually, one can get the panniculectomy covered." Fortunately, Dr. Wong says insurers are covering infraumbilical panniculectomies more readily since the 2007 debut of a separate CPT code (15830) for this procedure. Through 2006, he says, "They used code 15831 for both panniculectomy and abdominoplasty, despite the fact they are very different procedures." Now, he says, "Having a distinct CPT code specifically for infraumbilical panniculectomy has cleared some confusion on the part of insurance carriers. Today, if one does an abdominoplasty, there's an add-on code [15847] for this procedure."

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