How To Get A Tummy Tuck Covered By Insurance

Posted 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.

My short answer, after having done tummy tucks for 20 years, is almost no abdominoplasties get covered. So if you are a mommy who has had 3 kids and has some stretched out skin and diastasis (the muscle separation), unless you are truly blown out and look six months pregnant all the time, your abdominoplasty will be considered cosmetic. If you are a major weight loss patient who has lost 50 pounds, unless your skin is hanging low and you have chronic issues with skin breakdown, you are likely not getting your tummy tuck covered as well.

This is not to say I don't think there are real medical benefits from doing a tummy tuck. I think it is a true reconstructive procedure. But insurance does not always agree.

But what about those who are truly blown out? Or those who have lost over 100 pounds?

The criteria they listed as indicating your surgery is medically necessary by Medicare guidelines:

Inability to walk normally
Chronic pain and ulceration created by the skin fold
A large panniculus, which hangs below the level of the pubis (In English, your skin fold hangs below your pubic area)
Intertrigo (a rash and breakdown) of the pannus which is persistent or recurrent over a three month period (so you have skin breakdown which requires medical attention, has rashes, and breaks down for a long period of time).
Stable weight for at least 6 months, and are at least 18 months after gastric bypass surgery.

What wasn't covered?

Treatment of back pain
Repairing abdominal wall laxity or diastasis recti
improving appearance
Treating psychological symptoms.

My thoughts?

Urg. I love tummy tucks for what they do. There are studies which show statistical improvement in back pain and urinary incontinence (BLOG). My patients anecdotally state their bowel habits are better, their core is stronger, they can exercise better (one patient's golf game improved by 100 yards per hit), some even report better sex. It is a big operation, with a big scar and a real recovery. It is not to be done lightly. But do not use insurance coverage parameters as an evaluation of worth. Those who do abdominoplasties tend to be happy they did. It is frustrating to me and my patients that insurance companies do not include all the symptoms listed above as reasons to cover the surgery.

My other caveat with insurance coverage is for those with a large overhanging pannus, sometimes the insurance company will cover a "panniculectomy," not a tummy tuck. What this covers is technically a wedge of the overhanging skin, not a full tummy tuck where you undermine the skin up to the rib cage and corset the muscles back together. The muscle tightening and mobilizing more skin is part of what elevates the procedure.