Anthem BCBS—how to get approval for plastics?

[GSVguy 13]

I recently asked my primary care doc to see if we can get a panniculectomy approved by Anthem because of the under the belly button chafing issue, and that I think the extra skin is contributing to chronic back pain from degenerative disc disease. Also, I think I might have an abdominal hernia.

I had some non-elective skin surgery because of a bad injury, and the plastics doc I had was so great, I would like to deal with him again. My primary care doc agreed to refer me to him.

When I talked to his office, they said they do deal with insurance for non-elective procedures, but not for cosmetic procedures—and they consider a panniculectomy to be cosmetic even if it's for medical reasons.

What should I do here? I'd like to see if Anthem will approve the panniculectomy, let me go to my preferred plastics doc, and then reimburse me. Anyone have experience doing this? It sounds like a nightmare even trying and I'm not sure what my next step would be—but I really like this plastics doc.

Or should I just take my chances at another doc who will submit to insurance?

[GreenTealael 25,520]

1 hour ago, GSVguy said:

I recently asked my primary care doc to see if we can get a panniculectomy approved by Anthem because of the under the belly button chafing issue, and that I think the extra skin is contributing to chronic back pain from degenerative disc disease. Also, I think I might have an abdominal hernia.

I had some non-elective skin surgery because of a bad injury, and the plastics doc I had was so great, I would like to deal with him again. My primary care doc agreed to refer me to him.

When I talked to his office, they said they do deal with insurance for non-elective procedures, but not for cosmetic procedures—and they consider a panniculectomy to be cosmetic even if it's for medical reasons.

What should I do here? I'd like to see if Anthem will approve the panniculectomy, let me go to my preferred plastics doc, and then reimburse me. Anyone have experience doing this? It sounds like a nightmare even trying and I'm not sure what my next step would be—but I really like this plastics doc.

Or should I just take my chances at another doc who will submit to insurance?

As it was explained to me by a plastic surgeon I chose not to go with (I didn’t want to wait) :

It tends to be a long process to get insurance to pay for plastics. The need must be demonstrated over a period of time.

A patient would have to have documentation over six months to a year from doctors about the skin issues and rashes, be prescribed medication for it, have the medication fail to treat it for Insurance companies to even consider paying for it.

While that’s not an impossible task, it’s long. Also the surgeon must be willing to wait to be reimbursed after surgery (often less than their self pay prices) if prior authorization is not available for the procedure from your insurance company. This is likely the reason why many plastic surgeons do not want to deal with insurance companies.

Or you can pay upfront and ask the surgeon to submit a claim to insurance for reimbursement but there’s no guarantee you’ll actually be reimbursed.

Most people shop around while looking into plastics anyway, so you may be able to find surgeons who will except insurance if the surgeon you prefer cannot accommodate you.

Good Luck!