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karilhg

Panniculectumy appeal

8 posts in this topic

Hello, my name is karil and was before on this forum back in 2012 when I started my journey  to weight loss, but forgot my previous info, so decided start again.

I had a gastric bypass in September 2013, prior I had 2 C-sections and two ovarian surgeries (C-section like), I am happy with the weigh loss, but in the last summer I started to get this rashes under my apron's mom  (aka pannus) after the C-sections I pretty much lost pain sensitivity under my belly bottom but I get the rashes itching I could feel but not relieve . The rashes and the sweating (so much I would go to my panties letting me feeling like I peed on them) are making my HSV-2 breakouts come back more often, soooo.... cutting short to the end I saw a plastic surgeon and submitted a pre approval to my insurance, they are always pretty good fast to answer, my bypass surgery was approved a week after request was send, well I receive a denial from my insurance because "pictures didn't demonstrate excess skin" according to the policy "Panniculus extends below the inferior margin of the pubis ramus".

Well my apron doesn't cover my genitals but make my life hell, but also notice that there is a lot of skin sagging from my genitals, I want to appeal but don't know what way to go or how to demonstrate that my pannus is enough to  require s prompt solution, specially since recently I was diagnosed pre-diabetic and don't want those rashes become worse.

any help or advice is really really greatly appreciated 

Karilhg

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Welcome back Karil!

Best advice I can offer is to see your plastic surgeon again and ask if s/he can help with your appeal.

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I ditto what Cinwa said - if your insurance denied it, talk to your surgeon's office. In some cases, they can do a peer-to-peer (they speak with a physician at the insurance company) to explain why it is medically necessary. 

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39 minutes ago, delilas said:

I ditto what Cinwa said - if your insurance denied it, talk to your surgeon's office. In some cases, they can do a peer-to-peer (they speak with a physician at the insurance company) to explain why it is medically necessary. 

I didn't know this was a thing until a couple months ago, when my dad's back surgery was denied. His surgeon called and spoke with the insurance company, and then it was approved the next day.

@karilhg, your surgeon's office also may have some experience with getting procedures approved that have been previously denied. I've heard several cases now, where it seems to be all in how the surgeon's office articulates the need.

Best of luck to you friend.

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@karilhg Echoing what the others have said, your plastic surgeon can speak with someone at the insurance company. I would also keep a detailed log of the problems so you can show the excess skin is causing problems.

You can also challenge the criterion the insurance company is using. You can ask them why it makes any difference if the pannus is above or below the inferior ramus if it is causing you problems in the skin fold area. 

Good luck!

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thank you for the advices, my PS office called me they said to write a letter appeal to my insurance, I am trying to get all info I can and then take more pictures, I was also thinking talking to my PCP to see if an xray could show how low is my pannus.

Any help in how to challenge the insurance criterion about the length of my pannus.? I am collecting info and send a letter with a lot of resources and they better get ready because I am sending a lot of pictures of my lower body area not so pretty view of almost naked woman, lol.

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Truthfully, an xray isn't much more of a help than photo documentation, as they aren't good at demonstrating skin. I'd try taking photos - put your hand on your pubis ramus to demonstrate where it is, for example, or tie a measuring tape or string around you at that point. Other useful photos can be you pulling at the skin or leaning to show that it is loose skin and not fat (as another common refusal is that it is not demonstrated to be loose skin). If you are having infections or rashes of any sort, photograph these as well, and in your appeal, you need to write what measures and medications you've had to be on. 

BurgundyBoy and Stephtay like this

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I was going to suggest getting creative with how you stand to make it look longer. However the women's magazines tell you to stand to look taller and thinner? Do the opposite. 

Document your rashes. I've heard of some getting insurance to cover the surgery just based on rashes. Good Luck!

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