Class Action Lawsuit Over Insurance Coverage for Excess Skin Removal Following Bariatric Surgery Is On In California

In California, Kaiser Permanente is denying coverage for excess skin removal for nearly 10,000 patients who have had weight loss surgery. The question at hand is are they obliged to provide that coverage? Read more: (links to article) http://www.healthcentral.com/obesity/c/276918/175614/surgery-surgery-bariatric

Interesting. I recall facing similar obstacles when I coordinated a cleft lip & palette program. The insurance companies would routinely refuse coverage for rhinoplasty saying it was "cosmetic." I would then have to get the physician to write a more detailed note explaining why the procedure was medically necessary. I feel this same way about skin removal. Especially when it's a matter of skin folds and sagging skin that could harbor infections and rashes. I'd also argue the psycho-social aspect of sagging skin, but I understand that insurance companies aren't really that invested in that sort of reasoning. I am not there yet. I hope I won't have so much sagging skin that I need to consider skin removal surgery. I do know that both my primary and my orthopedic doctors have recommend documenting any issues I have with excess skin and should the need arise they will write letters in my behalf.

i can say this , my sister recently was forced to retire from one of the very very arge ins companies due to her MS. She was a nurse case manager. She has given this advice to me and we talk about it a lot. in order to get coverage you have to show the skin, either A. causes infections and rashes that are chronic ( usually 6 months of documentation) or for the panniculectomy if the skin interferes with sexual congress i.e. if it hangs down and hits your wee wee or hoo ha, in either of these cases it has to be covered as medically necessary otherwise its just cosmetic. I know from talking with my insurance they wil cover the panny if its touching my dingle dangle ( im in a weird mood , sue me) or if it becomes a source of chronic care 9 rashes, infections etc.

I would love to see updates on this article. This one doesn't say much.

@@Stevehud While this is a serious discussion, your response was totally entertaining. I would HOPE if the skin was in the way of sex, it would be considered medically necessary.....for heaven's sake! Insurance companies are not in business (and rich) for approving claims.

I wonder what the ripple effect of this would be, if more insurance companies routinely covered skin removal after massive weight loss following obesity? Sure, there would be more people seeking and getting plastic surgery. But would there be any negative repercussions?

I make sure my surgeon & pcp document every time I see them just for later on if I decide to remove the stretched out stuff because I know for sure my insurance won't cover unless it's medically necessary.

I have been a lifetime Kaiser member and I can tell you that member rates will increase to all of its members if procedures like these become common practice. I'm self employed and pay for my health insurance and already pay a small fortune for it. As much as I would like Kaiser to cover my tummy tuck, I know it would strictly be for cosmetic purposes and therefore don't think other kaiser members should front the bill for it. They told us in our Bariatric class that Kaiser will cover skin removal if it is significant and hangs over your private area or you have ongoing infections. I'm curious how bad this woman's skin is. I have had several surgeries during my lifetime and have never had an issue fighting Kaiser for any procedure I really needed.

@@Debbie3sons that is a very good plan. best to be prepared! plastic surgery is expensive and it surely would help if insurance covered some of it.

@@Bluesea71 that is an excellent question that you raise: I do wonder what the condition of her excess skin is? It very good to hear that Kaiser actually does cover the procedure if it is deemed medically necessary. i had the impression that they did not cover it, period.

I am self employed and pay for my own insurance, too, so I know it costs a fortune... ouch!

@@Stevehud - My ortho basically said the same thing. He said the minute you see a rash or anything else. start documenting. Take pictures, if you have to get meds/ointments to treat rashes, call the doctor first so there's a doctor's not on it. create a paper trail so you build a case. I honestly hope I don't need to, but I like having the option.

I wonder what the ripple effect of this would be, if more insurance companies routinely covered skin removal after massive weight loss following obesity? Sure, there would be more people seeking and getting plastic surgery. But would there be any negative repercussions?

I think it would go the same way most medical procedure goes. Initially there may be a slight uptick, but then eventually it will peter down to a reasonable level.

Before i had the WLS I did ask my insurance if they will cover any cosmetic surgery after it and they said yes because the company I work for required our insurance to have that. I got lucky in that part because they covered my WLS 100% and if I need any other cosmetic surgery it will be the same!!

I think that unless you have infections or there is so much skin dangling between the thighs that it interferes with walking it is cosmetic.

Sagging skin with no co-morbidities may not be attractive so it is a cosmetic problem. However, based on the CA statute I could see the argument to cover it since she did have a disease (obesity), she had treatment of that disease (WLS) and was left with sagging skin that she did not have prior to the obsesity. Skin removal would therefore restore her appearance. Most states don't have this statute. However if her plan is through an employer and ERISA based then that CA state statute would not apply. ERISA policies are generally exempt from state insurance laws. (Confusing isn't it?)

I think it is a fine line on what is cosmetic and what isn't is some cases. For most insurance breast reduction would be covered if the patient shows that they have been treated for back pain/shoulder pain and/or have rashes under the breast. There is normally a minimum amount of grams per breast that need to be removed to be approved.

Just having large breasts, having a tough time buying clothes, being teased or having men talk to your chest would not qualify for surgery. Mental distress is not normally a covered co-morbidity.

So how about a tummy tuck after pregnancies? Should that be covered? It is restoring the body back to prior to the pregnancy.

While I would love to have my insurance pay for a TT and panneculectomy I do consider it cosmetic unless I start to get rashes etc....

When I got my WLS approval letter it specifically indicated that the surgeries for skin removal was not covered.

@@Bluesea71 /quote]

YOU GO GIRL! Amazing!!!!

Louise

What if my batwings cover my hoo ha?