When is a panniculectomy a medical necessity?
My husband had gastric bypass in 2011, and now he's struggling with excess skin, causing him a significant physical functional impairment: he needs assistance to wash himself, isn't able to exercise, can't walk very well and so on and so forth. With these issues, is a panniculectomy a medical necessity?
My situation sounds a lot like your husbands. After having gastric bypass surgery, I experienced significant weight loss (about 100 pounds). Panniculectomy is often considered a cosmetic surgery, but my panniculectomy surgery was medically necessary and medical insurance covered it. My surgeon submitted the request to the insurance along with my symptoms. Excess skin hung over my genitals, and I had difficulty cleaning myself. My excess weight really impacted my daily living. My movement was even greatly restricted.
In my case, panniculectomy was not cosmetic surgery. It was a life-improving opportunity that gave me a second chance at living life. I needed the gastric bypass, and the subsequent panniculectomy removed the heavy skin and fat that continued to hold me back from becoming all that I could be. I recommend that you bring your husband to see a plastic surgeon and help him to complete the journey that he has begun.
After the healing process, my health has improved dramatically. I can exercise, which improved my circulation and breathing, and my self-image and self-esteem are much better. All insurance companies have different approval policies, but even if your insurance refuses to pay for it, most plastic surgeons offer payment options. It is worth it! The damage that obesity causes to your daily living is shocking once you come out the other side of this procedure. I hope that everything goes well for you.
What your husband is experiencing sounds very debilitating and given that the outcome of the surgery has impaired his ability to perform day to day functions, I do think a panniculectomy is a medical necessity. A person should feel more "able" after a surgery like gastric bypass, not more hindered in their mobility. If you are concerned about him being able to take care of himself as a result of the excess skin from his past surgery, it's completely fair to argue to insurance that this is a medically necessary procedure that without, your husband cannot continue to sustain himself or even work. If this skin is interfering with his ability to produce an income (which I assume it is, given that he's struggling to complete basic self care routine tasks), I would not hold back in making a case for why he should receive this surgery to empower him again.
I experienced a massive weight loss about four years ago. My panniculectomy wasn't about dealing with the cosmetic aspects of having excess skin after my weight loss. The surgery was about my health and comfort. I’m one of those people who dealt with a series of health issues that resulted from the excessive skin. My skin sagged below my pelvic bone and interfered with my ability to walk. I have a hernia and I also experienced skin rashes regularly. I had to use powders and creams to deal with the rashes. Having excess skin also creates hygiene issues. My everyday life was truly impacted. While I am not a fan of surgical procedures, this one really improved my life.
I had bariatric surgery and ended up losing a ton of weight. However, even though I fought off my obesity and was now at a stable weight I still suffered from a panniculus that would definitely need surgery. For me, it was mentally debilitating to have that apron hang over my pelvis. I couldn’t wear any clothes that fit me properly, and I had scarring from acne and “chub rub” under my belly that made it difficult to wear bathing suits or just be naked in general. I really hated my body, and I went into the procedure knowing that it may not be necessary but that I had to do it for me.
No one really thought that I needed the plastic surgery either. Everyone said I just needed to work out more and change my diet. Even then it was difficult to run or do any type of exercise with my gut in the way. In that sense, I knew the extra weight would be difficult to get off if it was putting so much strain on my body. Thankfully I had one of those doctors who really talks you through no matter what question you ask. It was important for me to hear everything that would happen during the surgery, and I didn’t want any pain. I will say the first week was pretty difficult because of how much fat and skin was removed, but I recovered the second week pretty quickly and I felt no pain at all by the third week. My doctor was there for everything and assisted me with whatever I needed. It saved my life I think. Now I’m very conscious about my body and work out constantly. The gym is no longer an issue either. It’s fun to get on the treadmill and see how far I can go!
I had a panniculectomy done, and my insurance company covered it. Your husband's surgeon will submit the paperwork to the insurance company explaining that the surgery is necessary instead of for cosmetic purposes. Elective surgeries are cosmetic in nature and aren't covered by insurance. My insurance covered my surgery because it inhibited daily activities of life and caused interference in my daily routine. If your husband is unable to care for himself, exercise and walk without the risk of falling, it sounds like a definite medical necessity.
The surgery changed my life by restoring my mobility and giving me independence, again. I was so happy to lose all of the weight, but I was surprised when I was still hindered by the sagging and heavy skin that hung from my abdomen. I couldn't be happier with my decision to have the reconstructive surgery.
Insurance companies, contrary to all the warm, fuzzy commercials, are not your friend. They are faceless bureaucracies that function for profit and provide a service....for a fee. They are not held accountable for their policies dictating coverage of certain procedures. They do not like to pay for things unless they have to. When treating cancer or heart disease, the medical necessity is obvious and failure to treat can lead to serious consequences. For other conditions, the medical necessity is less clear. Examples in my specialty include breast reductions and panniculectomies. In my experience, the only circumstances in which an insurer is likely to cover this procedure are: if there is chronic or recurring infection in the skin under the pannus, the pannus hangs below the level of the pubic area. Some insurers, such as Blue Cross Blue Shield actually have policies in place that do not allow for coverage of procedures related to weight loss. Good luck getting coverage for a panniculectomy.