Insurance DENIED. - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

ladybug · 04-03-2008, 11:26 AM

I am so depressed.. My insurance denied my TT and tigh lift.. I keep thinking this must be some cruel joke.. to top that off I have been exercising and I havent lost any weight in almost 3 months any suggetions on what i can do to get things going again. I am almost to goal only 10 pounds..I know it is skin weight but I am determind. HELP

Ruca · 04-04-2008, 05:35 AM

why would they cover it? Do you have well documented skin issues? Seems to me without that it would be considered cosmetic.

How much documentation do you have supporting issues?

coptergirl · 04-04-2008, 05:39 AM

I agree with Tammy. never give up, though. Appeal appeal appeal!

bridgetgirl · 04-04-2008, 06:31 AM

No one is covering legs at all anymore, period! I was one of the lucky ones who got it done before they put a halt on it. But if you want legs/thighs done you will have to pay for it oput of pocket.

As far the tummy goes, appeal it! Get your surgeon or the plastic surgeon you were going to go write one as well. Document all the "problems" and rashes you have! make sure you take pictures, lots of pictures! Appeal! Of course they are going to say no, at the hope you will walk away from it and save them money, but if you have the proof and the documentation that its medically necessary then do it. If anything after the appeal, if you are denied again there will be more specific reasons on the denial. Then you can appeal that with the info they give you if you are denied on the appeal. Never give up until you have exhausted every last resource. Anything worth wanting is worth fighting for... and honey, youre worth it!

MiladyB · 04-04-2008, 09:24 AM

My breast lift/reduction was first denied. This is what I did that really helped. I got a list of all of the criteria from my insurance company to see if there was some way I could get it covered. Once I had that information I sat down with my pcp and figured out the steps I had to take to get it covered. The biggest thing was DOCUMENTATION with my pcp...for the tummy tuck and the breast reduction. Basicly I called him MONTHLY to let him know about any continued rashes, back aches or anything else that would help me get the surgeries covered. It took several months but thankfully I was able to get both covered.

Don't give up. Keep digging and then fight it!

SueRN · 04-04-2008, 10:47 AM

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

ladybug · 04-04-2008, 11:09 AM

Thanks for all of the tips. I have been taking pictures so I will have to get woth the my doctor and nake a plan of attack. Im not giving up without a fight...

bridgetgirl · 04-04-2008, 02:33 PM

Niiiice Sue! S good to have you around! Im right about legs though, right? The last I hard no one is approving them at all.

Quote:

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

raindrop · 04-20-2008, 09:23 PM

has anyone had brachioplasty covered? just curious.

SueRN · 04-22-2008, 04:48 AM

Mine was denied. I appealed and lost. I will be paying for that out of pocket in Nov when I have a couple of revisions done. As far as thighs go, they rarely get paid for. The only cases I have seen get approved have reallly been majorly extreme cases. I just reviewed a TT the other day and she didn't meet the criteria but her pannus hung to her friggin knees! I reviewed it with the medical director and basically told him if she was a kangaroo, she could carry me and him in her stomach and he let me approve it. See, some insurance comapnies do have a heart....we're not all bad! I always try to advocate for my patients. I am willing to bet that in another 20 years, it will be manditory to conver more plastic surgery post op WLS as ignorance turns to knowledge and peopkle realize that the excessive skin is NOT just a cosmetic issue. 20 years ago, gastric bypass was thought of as more a cosmetic procedure than a medical one. Eventually......but that won't help me pay for my arms right now! Sue