Just_Dance16

2 Insurance denials for panniculectomy

4 posts in this topic

I haven't been on this forum since having my bypass at 16 in 2012! This site and the ladies helped me a ton and I am now 21 and doing absolutely amazing since losing the weight. 

 

Unfortunately I'm currently in a battle with my insurance company (IBX Keystone Health Plan East through the Philadelphia school district) trying to get approved to have this darn skin removed. My plastic surgeons initial request was denied due to them not feeling it was medically necessary. I appealed and submitted a letter I wrote along with some pictures of just a taste of the irritation caused.  I won't post my entire letter here but in short I explained that I was young when I had RNY, when I was out far enough to notice the skin .. and no doctor took the insurance I had at the time so I'd just forgotten about having it removed and tried to live and enjoy my new life. The more I lost the worst it got and unfortunately I was without insurance for about a year so was unable to see a doctor for any of my issues. I explained how disgusting and unhygienic this flap is, how it affects me not only physically but mentally because as a young woman this darn skin is so discouraging. They denied AGAIN this time noting my failed documentation. As I mentioned I submitted personal pictures showing irregularities  with my appeal and in my appeal denial reasoning it stated how the pictures didn't show any issues . ????? The rep I was assigned actually told me the pictures taken at my surgeons office were better and she'd use those (mind you they were only of my skin hanging taken in front)

since it began bothering me I've learned how to care and clean myself properly so that it doesn't get out of control but it is still such a pain. It smells like an armpit, and I feel like a baby with a horrible diaper rash at times .

my second level appeal is scheduled for Tuesday and I'm allowed to be on the phone for it . I honestly don't even want to proceed because I feel like they will just tell me to wait , let it get bad, have it documented and get a few attempts at treating it then come back and let us deny you again... the original plastic surgeon I chose refused to do a peer to peer with my insurance company so I thought to seek out another with whom I have an appointment with the day before my hearing . If denied again I will re submit with this new surgeon who is hopefully willing to advocate on my behalf for the medical necessity of this procedure for me . Any advice ir similar happenings and what you did would be appreciated!

 

thanks (: 

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Wow. Congrats you look amazing! Yes insurance companies are a big pain. I have been dealing with infections ever since my surgery and had the documentation from those visits by the time I was ready to remove the skin. And I still got denied and had to do an appeal. Not having insurance definitely sucks. I hope the interview goes well. If they deny you again ask how much documentation they need, how many infections or office visits. At least then you would know what you need for them to approve. Good luck. Don't lose hope. 

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When making an appointment with a plastic surgeon, ask right then and there if they will handle the appeals process. If they don't provide you with a satisfactory answer then don't make an appointment with them, and find someone else. There are plastic surgeons on every street corner and in every hospital. I know that Dr. Domanskis in CA told me that his practice works on the appeals process for their patients -- not many private practices do, as far as I know. I don't have first-hand experience but it is something that we discussed when I interviewed him for MyBariatricLife. You can listen to the video here: http://www.mybariatriclife.org/dr-edward-domanskis-bariatric-plastic-surgery-video-3/  He provides some good insights on bariatric plastic surgery being reconstructive rather than cosmetic. I also would encourage you to explore hospital plastic surgery departments because they may be more apt to fight for insurance coverage. 

Beyond that, you can go to a medical school like the University of Pennsylvania and get much lower cost plastic surgery. My friend had extensive bariatric plastic surgery and facelift done with Dr. Stephen Kovach and she was delighted. She paid much less than what ladies pay with a surgeon in private practice. 

And there's always Mexico... but choose very wisely and proceed carefully. 

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