Originally Posted by SueRN

Staci, Did they give you the reasons why it was denied? I have seen and reivewed many TT and can tell you that a lot, and I mean a lot, get denied because the documentation sent in is crap. When reviewing anything for medical necessity, we rely heavily on the MD notes, thank God most at dictated now as I do not read hyrogliphics too well, because we have not seen the patient ourselves. Like Beth said, get a copy of the medical policy that they used to review your case. See what specific criteria they need to see to approve. Just having rashes is not enough. Our policy is that a person has to have lost at least 100 lbs, is at least 18 months out, weight has been stable for 6 months, pannus has to hang at or below pubis, documented recurrent rashes that has failed conservative measures like hygiene, powders, lotions and topical antifungals, and have been treated with oral antibiotics or antifungals at least 2 times in a 6 month period. Skin has to have hardening and discoloration from the chronic recurrent rashes. I kinda overlook the last one when I review these myself cuz eventually they will get that if the pannus isn't removed anyway. Don't give up yet. Get more involved in the process and be your own advocate. Letters of medical necessity are nice, but we need to really see actual documentation of the visits, what was seen, what was dicussed, how it was treated and how it responded. Let me know if there is any help I can give you. Sue