Is Tummy Tuck Surgery Covered By Insurance?

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In: Insurance

Published on July 21, 2020.

I was taking my CME (continuing medical education), and one of the questions was about what makes your tummy tuck “medically necessary,” thus sometimes covered by insurance.

Unless you have lost 50 pounds and have chronic skin issues, it is unlikely that you will need a tummy tuck. However, if you are a patient who has experienced major weight loss and have a tummy that is sagging with loose skin, you may be considered for a cosmetic procedure called abdominoplasty. This is especially true if you have had three children and your abdominal muscles have separated (known as diastasis) and your skin has stretched. It is important to note that abdominoplasties have become less common in the past 20 years. So, in short, having multiple tummy tucks after 20 years is not the most typical solution.

This is not to say that I don’t think there are actual medical benefits from doing a tummy tuck, but I always disagree with the insurance procedure being considered as a reconstructive one.

But what about those who are truly exhausted? Or those who have lost more than 100 pounds?

The criteria they listed as showing that your surgery is medically required according to Medicare guidelines.

  • Difficulty in walking normally.
  • Persistent discomfort and sores caused by the fold of the skin.
  • A substantial panniculus, which dangles beneath the level of the pubis (In English, your skin fold droops below your pubic region).
  • You have a breakdown and rash (intertrigo), which is a recurrent or persistent breakdown of the pannus, requiring medical attention, that has been going on for a long period of time, such as three months or more.
  • Maintaining a stable weight for a minimum of 6 months and being at least 18 months post gastric bypass surgery.

    • What was not included?

  • Management of back discomfort.
  • Correcting abdominal wall looseness or separation of the rectus abdominis muscles.
  • Improving appearance.
  • Managing mental health symptoms.

    • My thoughts?

    It is frustrating for me and my patients that insurance companies do not include surgery for the above listed symptoms. Those who undergo abdominoplasties do not use insurance coverage as a parameter for evaluation, but they should. It is not a procedure to be taken lightly. It is a significant operation with a real recovery and a large scar. Some patients report improved sex, better golf games with longer drives, and stronger core muscles. Anecdotally, patients also report better bowel habits. There are studies that show statistical improvement in urinary incontinence and back pain. I love performing tummy tucks. Urg.

    Insurance coverage for those with a large overhanging pannus comes with a caveat, which is the procedure that technically covers the mobilization and tightening of the back muscles, corseting the muscles together, lifting the rib cage and skin, and undermining the skin where you tuck in the full tummy, not just a simple wedge that covers the excess skin.