watfam4

Hello,

I have a consult with a PS on the 01/05/09 and I "think" my chances of getting my insurance to cover my panni are pretty good, but I'm afraid to get my hopes up (I had to fight Cigna for a year to get my GB). Anyway, here's the situation:

- 3.5 years out from GB (465lbs => 265lbs)
- weight stable for 2.5 years
- pannus hanges down past pubic bone
- abdomoplasty/hernia (and a mass removed from GB scare) 2 years ago

I had consulted with a PS prior to the abdomoplasty/hernia repair and was denied (by Cigna HMO) as I was not having any real skin "issues". When I went to my surgeon to consult on the hernia repair they also discovered the mass below my sternum (btw - not malignant). I decided (at that time) it was best not to wait and fight the insurance company to also get the panni.

Now I have another mass growing in the fatty tissue of the pannus (1" - 2", soft, aches a little) that may or may not be related to the first mass. My primary care doctor and surgeon have agreed that it should go (not overly concerned, but cautious), and that this would be a good time to have the panni done by a PS. My general surgeon even wrote a letter to this effect for my PS (without me asking...good doctor!).

The other thing is my insurance will change to BCBS on 1/1/09. My hope is that they are not any worse than Cigna.

I am trying to NOT get overly excited as I've been disappointed by my insurance company in the past. I am cruising the boards trying to glean any information I can get on BCBS and medical necessity for a pannulectomy.

I REALLY had a tough time with Cigna on the GB (3 appeals, hired a lawyer, letters to the State, etc.), and I REALLY do not want to have to go down that road again.

I apologize for the novella. Any advice, tips, links, would be greatly appreciated.

Thanks!

sgfam81

Wow, I don't have any tips per se but I wish you the best of luck. I've heard that BCBC (depending on what plan you have) doesn't always make you go through all of the hoops when getting the surgery, so maybe it will be the same for this surgery related PS procedure. Have you been able to get a copy of BCBS' policy for this procedure? Please keep us updated on your progress. Just try to stay positive and keep your head up when dealing with the insurance company.

watfam4

Thanks for the encouragement. I hope you are right on BCBS. I really do not need the frustration. I have not seen a their policy booklet yet. My employer is historically awful at getting these booklets out.

From some of the threads on Tummy Tucks it sounds like the it is usually more difficult to get the insurance to cover the Abdominoplasty than the skin removal. Since I am only needing the skin removed, I am hoping this makes the BCBS decision easier. I guess we'll see.

sgfam81

Definitely keep us updated! You should be able to request the approval docs from the BCBS directly, no? I know prior to submitting to insurance a case manager from my insurance company was able to email the detailed, step-by-step, letter-by-letter (what i'm getting at is that this was a LONG documents lol) criteria for Bypass approval. BCBS may do the same for this PS instead of having to wait on your employer.

__________________
Shante'
Ready for a new life!

Lap RNY: 12/22/08
Highest/Pre-Op/Current/My Goal
399 /383/350/180

watfam4

I hope so. With Cigna we were lucky to gain access to their policy booklet by 2nd quarter.

When I was dealing with Cigna on my GB, I know for a fact that the Cigna representative did not have my up-to-date information. When I was finally approved (May 2005), the Rep was still quoting (incorrectly) policy criteria from the previous year

watfam4

I saw the PS this morning and his office will be submitting to BCBS to get the panni removed with the lump. The PS took all of my info (and embarrassing naked photos...again). So the process has started.

I am feeling a little nervous (still snake bit from GB approval process through Cigna). Anyway, I feel like I should be running around to get a bunch of letters, documentation, etc. But I am sure that BCBS will let me know if they need anything else. Now the waiting begins...

Wish me luck!

sgfam81

Sorry I haven't been on the site in a while, but... GOOD LUCK! More photos? That bites. But at least the process has started. Don't worry about that old snake bite. Consider that snake dead and gone. Did they give you any idea how long it usually takes for review?

__________________
Shante'
Ready for a new life!

Lap RNY: 12/22/08
Highest/Pre-Op/Current/My Goal
399 /383/350/180

watfam4

I found out that BCBS (National PPO) no longer do pre-determinations for medical procedures. According to BCBS, they were having difficulty with doctors performing additional procedures than what had been previously approved, so they just stopped doing them.

So my first hurdle is that my PS office can not find out (for sure) what is going to be paid by BCBS, so they want me to pay for half of the procedure up front (just in case). Which I understand, as the PS office does not want to fight with the insurance company any more than I do.

This, of course, is ridiculously silly. How can medical necessity be determined without some sort of medical review?? I know we have a list of criteria for different procedures. But like co-morbidities for WLS, some things are subjective and require a person with medical training to review in order to get a full picture of all related issues. (this makes me wonder if/how people even get WLS through BCBS)

Anyway, I have been calling and emailing both BCBS and my HR department to get some type of resolution to this. The good news is that I have gotten BCBS to give me an "unofficial" review by their medical staff and should hear back next week. Assuming that BCBS will OK it, my next hurdle will be to get my PS to accept an unofficial OK from BCBS (and not make me pay the up front money). The bad news is that my UN-Glamor Shots are now circulating around BCBS Maryland office with my pre-determination packet

(rant completed...I feel better)

watfam4

I got word today from BCBS that they will cover the panniculectomy. However, what they will not do is any written confirmation (pre-determination) for my surgeon. So, apparently, my up front cost will be determined by how much my surgeon "trusts" BCBS to pay.

This is just silly!

My BCBS rep did provide some additional documentation with BCBS guidelines for cosmetic vs. reconstructive surgery. Hopefully this will be enough for my doctor. We'll see.

Kimberly76

is there an update with this?

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Kimber~