Navigating Cosmetic Procedures: Steps to Getting Your Tummy Tuck Covered by Insurance

According to the American Society of Plastic Surgeons (ASPS), the number of people getting a tummy tuck has steadily increased. There are over 120,000 tummy tuck procedures performed in the US annually. Do you have excess fat, loose skin, or another condition that a tummy tuck can address? Unfortunately, tummy tucks tend to be expensive. The ASPS puts the average cost of a tummy tuck at $6,154, but the procedure can easily cost $10,000 or more. 

One way to combat this cost is to get your tummy tuck covered by insurance. However, insurers can make this process complicated. Many insurers won’t cover tummy tucks unless you have a necessary medical reason. A tummy tuck is commonly considered merely a cosmetic procedure. This article will examine the steps to get your tummy tuck procedure covered by your insurer and other considerations you should make.

1. Check What Procedures Your Insurer Covers

Not every insurer and insurance plan is created equal. Depending on your coverage, you may or may not qualify for a tummy tuck procedure. Critically, cosmetic surgery benefits are often not included because insurance typically only covers “medically necessary” procedures. The National Association of Insurance Commissioners (NAIC), which sets standards in the industry, asserts that many insurers look for several elements to be present in a healthcare service before they cover it. These elements may include

  • The service provides relief for a valid medical condition in some way. This can include diagnosis, treatment, cure, or other ways of interacting with your condition.

  • Any procedure must be accepted as legitimate by the opinion of the professional medical community.

  • It must be reasonable for this procedure to be deemed medically necessary or appropriate for your condition.

  • The procedure must be cost-effective. This means there cannot be an alternative treatment or service that you could use instead.

These elements are the basic guidelines insurers will use to determine coverage. Guidelines can vary by state and insurer.

2. Satisfy Insurance Requirements

Even if your insurer may cover part or all of your tummy tuck, you should also consider other requirements you must meet. These requirements include:

  • Deductible: Your policy may have a deductible, which is the amount you need to pay from your own pocket before insurance will start to pay benefits.

  • Copay: With a copay, you will only have to pay a certain amount for medical services. Copays apply for things like doctors’ visits and medication. You will typically qualify for a copay after you have paid through your deductible.

  • Pre-approval: A health insurance plan may require many kinds of medical services to undergo a pre-approval process. To get pre-approved, you must submit information about the procedure’s medical necessity to ensure it conforms with your insurer’s policy. It is important to note that just because your procedure is pre-approved doesn’t mean the insurer is guaranteed to cover it. You still have to submit an insurance claim like normal.

  • Limits on services: An insurer may limit the number or frequency of covering certain services. For example, they may have a yearly cap on the amount of doctor’s visits they will cover. This can be difficult for a tummy tuck, where you may need multiple visits to prepare for finally undergoing the procedure.

3. Get A Doctor’s Recommendation

You must ask your insurer if a doctor’s recommendation is necessary to get insurance coverage. If you go through with the procedure without getting a proper referral, your insurer may be able to deny your claim after you file it. If you have already started attending doctor’s visits in preparation for the tummy tuck, you should work quickly to get a valid referral. If your benefits are denied for the procedure, a referral may help at least cover the cost of your visits.

To get a valid doctor’s recommendation, you must establish a doctor-patient relationship with a physician certified to practice medicine in your state. Your insurer will have a list of valid doctors in your insurance network. You must use one of these doctors to ensure you have the highest chance of getting your claim approved.

4. File a Claim

You must submit an official form to your insurer to file a claim for your tummy tuck. Your insurer likely has forms available to download online, but if not, you may need to contact them directly to get one. The form will require you to provide certain kinds of information, which include:

  • Treatment dates

  • Information about your treating physician and medical care facility

  • Copies of any receipts and treatment information you have, which insurers use to evaluate the legitimacy of your claim

  • Your policy number

Be sure to keep a copy of everything related to your treatment. You set aside as much information as possible so you are prepared when it comes time to file your claim. Insurers may reject your claim for missing information, which can slow down your reimbursement.

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5. Consider Alternative Options

You may pursue other options if you cannot get your health insurance provider to cover a tummy tuck. One standard alternative procedure to a tummy tuck is called a panniculectomy. A panniculectomy is a procedure that can help remove excess skin near the abdomen. This procedure is often recommended to patients who have undergone rapid weight loss. The main difference between a panniculectomy and a tummy tuck is that a panniculectomy doesn’t focus on aesthetics. This surgery is mainly concerned with addressing the health issues of overhanging skin. The results will not look as good as a tummy tuck cosmetic surgery.

Another option to consider is to apply for coverage through Medicare or Medicaid. If you need surgery purely for cosmetic reasons, you will still not get covered, but government medical services may more efficiently cover a portion of your treatment than a private insurer will. To qualify for Medicare health insurance, you must be over 65 years old. Medicaid is available if you meet low-income financial requirements and are a United States citizen.

Tummy Tuck Insurance Coverage FAQs

Did the steps above answer your questions about getting a tummy tuck covered by insurance? If not, look through people’s frequently asked questions about tummy tuck insurance coverage.

Will an Insurance Company Always Cover a Tummy Tuck After Extreme Weight Loss?

Not always. While your insurer is likely to cover any necessary weight loss surgery you need, tummy tucks are often excluded because of their nature as a cosmetic surgery. Don’t assume that your insurer will automatically cover you for a tummy tuck just because you have a lot of weight to remove.

Do Most Private Insurers Cover Tummy Tucks?

No. Most insurers do not cover elective or cosmetic procedures like tummy tucks. To get a surgery approved by an insurer, you must prove it is medically necessary. Although tummy tucks provide health benefits, other surgeries can accomplish the same results with a focus on being cosmetic. If you had a health condition that a tummy tuck could fix, there is likely a more necessary procedure that the insurance company would cover instead.

Are There Conditions That May Disqualify Me From Getting My Tummy Tuck Covered?

Yes. If you are obese, then a tummy tuck may not produce the results necessary to address your medical needs. You may need to demonstrate an ability to maintain a stable, healthy weight first. Because the surgery affects the abdominal area, the procedure is not recommended for those who are pregnant or who may likely get pregnant in the future.

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