BIG lawsuit over insurance coverage for post-surgical excess skin removal

[CourtWatcher85 2]

Hi everyone,

Has anyone ever had an issue with not being able to get an insurer to cover Excess skin removal after your procedure? If so this might be of interest to you. A class action trial began this week in California against Kaiser, which apparently never covers skin removal for weight loss surgery patients because it is "cosmetic."

http://blog.cvn.com/class-action-trial-over-kaisers-plastic-surgery-coverage-begins

[JerseyCityGal 231]

I can sort of see their point, because where does it end? Everyone who has a baby will want a Tummy Tuck, etc.

I have United HealthCare/Oxford and have to do self-pay for all my skin removal. I really wish it was covered by insurance. UHC does not cover it under any circumstances. They don't care if your belly is dragging on the ground.

[WL WARRIOR 690]

What if the excess skin impacts you mentally/emotionally? Do you think that is just cause for insurance coverage of a TT?

JerseyCityGal, I agree with your statement. If I never gained 70 pounds during my pregnancy before my sleeve surgery, my stomach wouldn't be in such bad shape. Although I'm sure thousands of women that DO get insurance coverage for plastics after bariatric surgery have had a pregnancy beforehand.

[JerseyCityGal 231]

I think it's a real problem.

My excess skin impacts me mentally and emotionally, but I didn't have a brain tumor that caused me to gain all my weight. I did it to myself.

I'd love to have someone pick up the tab for the end result of my actions, but when the insurance companies start doing that, it's a slippery slope.

Why should everyone pay for what some of us chose to do to ourselves?

[Bufflehead 6,358]

Lots of issues considered to be cosmetic affect people mentally and emotionally. I'm embarrassed and humiliated by my large breasts, does that mean I get insurance coverage for a breast reduction even though they are not physically causing me problems? What about someone with a big and misshapen nose? Ears that stick out and lead to teasing? Just about any cosmetic surgery could be covered if the only criterion was that it affects you emotionally.

eta: I can see how Kaiser's lack of coverage would be in violation of the California state statute, which requires them to pay for reconstructive surgery needed to return a patient's appearance to normal after trauma or disease. Surgery = trauma and obesity = disease so they may indeed have a good case against Kaiser.

Edited March 18, 2015 by Bufflehead

[samuelsmom 670]

As a nurse, I believe that there can be clear medical indications for tummy tucks. For example, people who have recurring infections and skin breakdown due to increased body folds. This can be very serious and put someone in the hospital on IV antibiotics.

I don't see why a qualified panel cannot do the evaluation and come up with specific criteria. IMO, I don't agree with psychological effects as a rationale for insurance to cover. As Bufflehead said "Just about any cosmetic surgery could be covered if the only criterion was that it affects you emotionally."

[lisacaron 5,075]

So yes this can be a slippery slope for insurance companies, doctors and for patients. There are many things that are covered, As @@Bufflehead mentioned, large breasts yes you are covered for a reduction, nose yes you are covered for nose job. Most of the time these things are covered by saying they impact some form of physical being with the patient. Large breasts impact body frame and walking damaging spine causing back pain etc. In the long term it's cheaper to reduce your breasts for you then for them to treat all the related probable symptoms and affects of being top heavy. Same could be said for a nose job if it affected your septum and your sleep and productivity and sinusitis. etc.

The very same could be true for skin surgery if it is impacting your walking or sleeping or moving. If you are experiencing rashes or other trauma from having this excess skin. Most of the time this is what is needed to be documented by your Dr's so that the insurance company can validate the claim for surgery.

Sure in someways it's cosmetic, but as some of you have mentioned its a mental and emotional thing as well. Should you gain all your weight back because you don't like to look at that skin? The treatment of your obesity and the co-morbidity from obesity could be used as an argument. As well as all the physical affects you "might" suffer from if you have a belly that's hanging. Sitting, standing, walking can all cause discomfort and lead to gait issues and spine issues and foot problems and we could go on and on...so just like everything else. It will come down to a case by case decision.

So document often and early if you have symptoms and you may have a stronger case when you advocate with your insurance company....

[Sherrischeffler 74]

If excess skin hangs past crotch area on men/ women insurance usually will pay but Dr must submit photos & a report.