Upon reviewing the submitted information, I have determined that at this time "Excision, excessive skin and subcutaneous tissue; abdomen, infraumbilical panniculectomy" is not a covered benefit under the benefit plan. This determination is based upon the following plan language, found on pages (s) 74 and 125 of the member's Certificate of Coverage or Summary Plan Description:"Excluded ..... Cosmetic procedures, including cosmetic surgery expenses, supplies, appliances and drugs, except for reconstructive surgery to repair accidental injuryCosmetic Procedures -- services are considered Cosmetic Procedures when they improve appearance without making an organ or body part work better. The fact that a person may suffer psychological consequences from the impairment does not classify surgery and other procedures done to relieve such consequences as a reconstructive procedure."
If a credentialed provider determines a specific course of action is reasonable for medical therapy it is amazing that insurance companies can countermand that judgment. Providers may be working as patient advocates, but clearly insurance companies are looking out for their own selfish bottom line. Not a new revelation as most of us would agree.