When should insurance cover body contouring?

Today in clinic, I interviewed a formerly morbidly obese woman. She has lost almost 300 pounds since undergoing gastric bypass surgery a few years ago, a presentation that has become increasingly common. She was here to see the plastic surgeon for her four week follow up appointment, status post abdominal skin flap removal.

See, after losing a ton of weight, loose skin remains, especially in places like the arms and abdomen.  The loose flap of skin is termed “pannus,” and the surgical excision of loose flaps of skin following massive weight loss is termed “body contouring.” The abdominal pannus is clinically relevant because it can strain one’s back or interfere with leg movement. The pannus also creates excess surface area that is hard to keep clean and hygienic. Rashes and ulcers and other painful things can develop as a result.

Luckily, this woman’s insurance covered her abdominal body contouring procedure because of how it would contribute to her quality of life. She was a pleasant lady, and so grateful to the plastic surgeon, but it was clear that there was something about her body that still bothered her even after all these procedures.

The elephants in the room were the huge saddlebags of excess fat that remain on her thighs. You can imagine how self-conscious that would make someone feel. What her insurance won’t cover is the body contouring procedure it would take to transform those log-legs into something she could at least stuff into a pair of stretch jeans. The rest of this patient’s visit comprised of removing her abdominal drain and reassuring her of the plastic surgeon’s optimism that she’d be able to go shopping for a new wardrobe soon.

Just as long as some paperwork gets filled out, she’ll be able to have the thigh reduction surgery further down the line, though it will cost more than she would like. Should her insurance help her out and cover much of the cost of this additional body contouring procedure?

If you’re on the patient’s side, you would think insurance should cover her thigh reduction surgery, as this would undoubtedly help improve her quality of life, health, and well being. This patient hopes to one day chase around her two adorable grandchildren and not worry about her inner thighs chafing together. On the other hand, if you think about the health care system as a whole, thigh fat removal surgery is perhaps somewhat appropriately not considered a priority.

Americans are always on the lookout for ways to cut health care costs and make quality health care more affordable and accessible. How do we discern which medical interventions are the most sustainable, cost-effective use of our funds and resources? To discover real solutions in health care, we must be honest with ourselves about what we’re spending money on now. Health education and physical activity are currently not priorities of American culture and lifestyle. Simply visit any airport or theme park in America for proof. We are now notorious for the rates of obesity and diabetes in our country.

Chronic disease in general is expensive because it involves long-term medical management, a myriad of medications, and increased morbidity. According to an article in the American Journal of Surgery, the incidence of bariatric surgery has peaked and remained stable since 2003, with approximately 113,000 cases performed per year. This same study reveals that bariatric surgery costs the health economy at least $1.5 billion annually. It is difficult to find data on the cost of any body contouring procedures that undoubtedly follow.

Open gastric bypass now constitutes only 3% of all cases but costs $4,800 less than its laparoscopic counterpart. Despite its simplicity, laparoscopic gastric banding costs the same as gastric bypass. Complication rates following bariatric surgery have fallen from 10.5% in 1993 to 7.6% of all cases in 2006. At least we’re getting better at bariatric surgery and the amount of money it costs us each year is not increasing.

Unfortunately, bariatric surgery is still considered a last resort to improve the quality of life of a morbidly obese patient who has no other medical options. As obesity and other chronic diseases trend upwards, it is not a stretch to say that an increasing amount of our medical resources is being spent on this type of health care.

As a medical student and future doctor, I envision a health care system that focuses on encouraging, maintaining, and prolonging quality of life. A system that prevents disease would save more money than a system that focuses on treating disease once it occurs. I hope to see increasingly fewer patients in clinic who have to buy back their quality of life from a chronic condition that potentially could have been avoided altogether.

Nonetheless, by reducing her thighs, my patient in clinic today will still ultimately contribute to the cause of preventive health. She will be able to run around with her grandchildren and help them establish habits of activity that could last them a long, healthy lifetime.

Stephanie Van is a medical student.

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  • Guest

    I want to look like Brad Pitt. Looking like Brad Pitt would make me happy, and if I were happy I’d get out more and would be healthier. I should get that for free.

    Everyone should get everything they want for free.

    • Stephanie Van

      brad, having the body you want IS free. well, at least, it costs fewer health care dollars than having the body you don’t want. anyone can look like brad pitt for free because push ups and making healthy food and lifestyle choices doesn’t cost money so much as self-dedication. you are making an important distinction between a body that costs money vs. a body that costs hard work and sweat.

      maybe a gym membership costs more than indulgent meals in America because corn syrup is so affordable. but the time we spend not breaking a sweat costs us money in our long term health care. medical treatments and insurance coverage do not exist to make us happy and thus healthier. they exist because inevitably our own attempts to maintain our health and happiness are nonetheless thwarted by disease. it is up to us how quickly we allow our bodies to be thwarted.

      • FEDUP MD

        Wow, I just have to work hard enough and the body I want will happen? Have a few kids and see. Sometimes things just don’t go back to where they used to no matter what….. Well, short of surgery that is.

        • Stephanie Van

          I can’t tell whether you’d pay for the surgery yourself or if you’d prefer your insurance company to cover the cost because no amount of physical activity will undo what pregnancy can do to a woman’s body.

          I am not against people electing to have body contouring surgery so they can have the body they want. Go for it. What is in question is where the money is coming from to pay for these types of surgeries.

          • FEDUP MD

            That was not the thrust of my argument, about who pays. What I dislike is when some chipper 20 something says anyone could look like Brad Pitt if they worked hard enough. I thought so too when I was younger until I developed serious health issues, as well as had kids, and began as a physician working with people withe serious health issues. It’s amazing how much that changes your perspective and your compassion. If your counselling to patients consist of anything like you said above, good luck with convincing your future patients to make healthier choices.

  • Laura Cox Witherington

    Your logic works, except in considering that there are not limitless funds, even in the pockets of insurers. Shouldn’t the leg surgery be her option if she chooses to pay for it herself? Also, I have to think that if she eats healthily (not just under caloric limits, but good, healthy food) and exercises regularly, some of the leg fat will drop. Not all, but some. Also, we need to educate people so that they understand that some things they do to their bodies are irreversible. Gaining 300 pounds means a body will never return to its earlier shape.

    • Mengles

      No limitless funds? They definitely don’t teach that in medical school. In medical school, everyone should get “free” healthcare” bc it’s a “right” and if you’re not healthy, it’s your doctor’s fault.

      • Stephanie Van

        if you’re not healthy, blaming only your doctor for your poor health is your fault.

        • Guest

          At some point before graduation, you’re going to need to learn how to use the shift key.

          Writing in all lower-case is an adolescent affectation that makes you look like a seventh-grader.

          • Stephanie Van

            Thank you for your comment. I hope the content of my writing dispels any illusions that I am a seventh grader.

          • Mengles

            If anything, it seems to confirm it.

          • Stephanie Van

            Seventh graders everywhere would be heartened to have someone as eloquent as yourself be such an active participant in the comments section of their essays.

    • Stephanie Van

      laura, i like where your head’s at. i don’t think anyone in America who has required medical services is under the illusion that our healthcare system has limitless funds . my patient will ultimately end up paying for most of her thigh reduction surgery herself, and that is her option just so much as her personal funds allow. it’s true, “we need to educate people” – education is important, education will help people realize not only that “some things they do to their bodies are irreversible” but also that everything they do to their bodies affects their health and happiness.

  • Suzi Q 38

    IMHO, she should pay for it herself. This is cosmetic.
    I have two family members and one friend that has had the bariatric surgery.
    Two have almost regained their original weight within 5-7 years.

    Your patient can wear leggings that contour her legs, and pants with wider legs.
    My family member has the fat hanging under her arms, but she can wear shirts with sleeves.

    She can also pay for it herself.

    I have an indentation on my leg from a soccer injury sustained 15 years ago. The doctor said that I would have to call in a plastic surgeon.
    I would have to pay for it myself, if I wanted it to “go away.”

    I need a tummy tuck, too. I am 57 and look O.K., (well my husband still thinks I am cute), but I would like a surgeon to remove the fat.

    Should my insurance pay for it???

    They should save their money and make their own personal decisions on how to use that money.

    A doctor can always make up some medical excuse to try to get it covered by insurance, including the bariatric surgery itself.

    • Stephanie Van

      suz, i bet your husband isn’t the only one who thinks you’re still cute. i love hearing people be realistic about and embrace their imperfections. there is no need to hold ourselves to anyone’s aesthetic standards but our own. but what about our health standards…?

  • Stephanie Van

    brad, having the body you want IS free. well, at least, it costs fewer health care dollars than having the body you don’t want. anyone can look like brad pitt for free because push ups and making healthy food and lifestyle choices doesn’t cost money so much as self-dedication. you are making an important distinction between a body that costs money vs. a body that costs hard work and sweat.

    maybe a gym membership costs more than indulgent meals in America because corn syrup is so affordable. but the time we spend not breaking a sweat costs us money in our long term health care. medical treatments and insurance coverage do not exist to make us happy and thus healthier. they exist because inevitably our own attempts to maintain our health and happiness are nonetheless thwarted by disease. it is up to us how quickly we allow our bodies to be thwarted.

    laura, i like where your head’s at. i don’t think anyone in America who has required medical services is under the illusion that our healthcare system has limitless funds . my patient will ultimately end up paying for most of her thigh reduction surgery herself, and that is her option just so much as her personal funds allow. it’s true, “we need to educate people” – education is important, education will help people realize not only that “some things they do to their bodies are irreversible” but also that everything they do to their bodies affects their health and happiness.

    suz, i bet your husband isn’t the only one who thinks you’re still cute. i love hearing people be realistic about and embrace their imperfections. there is no need to hold ourselves to anyone’s aesthetic standards but our own. but what about our health standards…?

    thank you for all of your comments! – OP

  • T. McIver

    If we’re going to expect that “insurance” start covering things like cosmetic surgery, we should probably stop calling it insurance — it’s more like a pre-paid health plan. And we’ll need to accept that the more we want health “insurance” to cover, the more it’s going to cost.

    Imagine how much car insurance would cost if it paid for all
    expenses associated with owning an automobile – oil changes, engine
    failures, worn-out tires, brakes, rust, and so on. The number of people
    who couldn’t afford car insurance would rise dramatically, and we would
    have a car insurance crisis in America.

    The same, if home insurance had to cover painting, gutter-cleaning, yard maintenance and buying you a new sofa when you let your kids jump on the old one and they wreck it.

    Getting fat, and then getting thin, and then wanting surgery to make it all pretty, is not covered under any standard definition of “insurance”.

  • Mengles

    Whenever I want a good laugh, all I have to do is read one of these articles written by naive medical students, which it seems like the bar is being lowered day by day. Who else can come up with gems like “What her insurance won’t cover is the body contouring procedure it would take to transform those log-legs into something she could at least stuff into a pair of stretch jeans” and “Nonetheless, by reducing her thighs, my patient in clinic today will still ultimately contribute to the cause of preventive health.” And then we wonder why premiums are skyrocketing.

    • Suzi Q 38

      Admit it Mengles,
      You are just jealous.
      Her blog was about and adverse effect of bariatric surgery.
      It was a little different, and you actually read the whole thing.
      You even posted, even though it was about as positive of a post as I have seen you post in awhile.
      If you are so above it all, why comment?

      I imagine that you were also entertained.

      • Mengles

        Yes, that must be it.

    • Stephanie Van

      i’m glad you got a good laugh out of reading my essay and writing me off as another naive medical student. it’s too bad that that’s all you seem to have gotten out of it.

      • Mengles

        Yes, if someone believes that “body contouring” should be covered by health insurance which has gone from catastrophic coverage to covering everything under the sun then yes. In any other situation, you would be laughed out of the room, with such an insane idea as you seem to not know how expensive health insurance is now.

        • Stephanie Van

          my essay does not conclude that i believe body contouring should be covered by health insurance, perhaps you should read it again. i simply state that if my patient’s insurance covered pannus removal because it contributes to quality of life, wouldn’t it follow that insurance should also cover her thigh reduction surgery since it would achieve the same end? i agree, this is not a worthwhile use of insurance money.

          on the other hand, i also discuss how ridiculous it is that we spend so much money on curing preventable disease and its detriments to quality of life. my concluding sentences try to find a bit of hope in this situation, where at least my patient’s grandchildren might be encouraged by their grandmother’s attempts to be healthier and physically active with them. but maybe those attempts should come from her personal funds because her regaining her health is her responsibility.

  • Disqus_37216b4O

    The title of this blog post is “When should insurance cover body contouring?”.

    The answer for anyone who is concerned about skyrocketing insurance premiums should be “Never”.

    Next?

  • Guest

    Stephanie, all physicians are not as angry and disgruntled as the folks posting here. I enjoyed your essay, and I wish you the best of luck on your path. You will meet lots of physician bullies but I hope they don’t demoralize you or hinder you in any way. They are the ones with the problems (and I’m sure every negative physician poster in here would agree that they’ve got loads of baggage they’ve not dealt with properly).

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