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reconstructive vs cosmetic

  1. Default reconstructive vs cosmetic
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    would a breast augmentation and a tummy tuck be considered reconstructive or cosmetic plastic surgery. For the person I am asking for they had gastic bypass done and have lose skin and want to get it fixed but the insurance denied the surgery saying it was cosmetic and not reconstructive.

  2. #2
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    Columbia, MO
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    Sadly this is considered cosmetic. Unfortunately for most(but not all) insurance a "tummy tuck" is considered any thing other than cosmetic unless the physician documents several occurances of skin infections with necrosis due to the panis. Also the panis must hang down by so many inches. It is unfortunate.
    Reconstruction is when there has been trauma or a neoplasm removed that has caused a defect which needs plastic repair to return the patient to whole.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    I just found out from the person that the physician documented that because of the looks skin she is getting rashes and is prone to infection. but the plastic surgeon wont see it and is just assuming its cosmetic

  4. #4
    Location
    Columbia, MO
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    I see the Physicians point but you will need a stronger argument than just prone to infection. Unfortunately you have show that there are or have been infections, along with pictures. He can try with what I call a letter of medical need. This where you will need clear evidence that this is not cosmetic at all that it is for medical necessity. Picture will help along with any research citations. However without the patient having had recurrent infections already it will probably be denied. That is why the plastic surgeon is not playing ball.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    it just sucks because the surgeon wont even see the person to check it out own his own even though he will be getting paid for it.

  6. #6
    Location
    Milwaukee WI
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    Default Not seeing the patient?
    Quote Originally Posted by cingram View Post
    it just sucks because the surgeon wont even see the person to check it out own his own even though he will be getting paid for it.
    I do not understand this statement. Who is requesting pre-authorization for the procedure? It should be the surgeon who will be performing the procedure. And that surgeon's office would take pictures and write the necessary letters to get coverage for the procedure. (Or, if nothing worked to get insurance coverage, that surgeon's office would be working out payment plans with the patient.)

    The vast majority of these cases (loose skin post gastric bypass or other extreme weight loss) are considered cosmetic.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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