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Panniculectomy Insurance Denial


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Hi I'm actually new to this site but I had my gastric bypass 4/5/06 I'm having several issues with rashes under my belly and in my belly button and I just went to see a plastic surgeon for a possible panniculectomy and my insurance denied it and this is my first attempt though so I think I will appeal does anybody know any good ways to get my appeal approved any tips that I should use or could use and it research that I can do?

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19 hours ago, Gmaof3 said:

Hi I'm actually new to this site but I had my gastric bypass 4/5/06 I'm having several issues with rashes under my belly and in my belly button and I just went to see a plastic surgeon for a possible panniculectomy and my insurance denied it and this is my first attempt though so I think I will appeal does anybody know any good ways to get my appeal approved any tips that I should use or could use and it research that I can do?

I've heard the following helps - document your rashes with photos and dr visits. Does your insurance require that your belly hang down a specific length? If you don't know, find out. The woman who ran the offline support group I was in when I was newly post off had a panniculectomy covered by insurance and she suggested anyone who is interested to keep documenting and appealing. Good Luck!

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  • 2 years later...
8 hours ago, Karlaen said:

My insurance just denied my request for a panniculectomy.  I am 4 years post op from having the gastric sleeve.  Does anyone have a successful letter they used to get an appeal approved?  I could really use some help!  

From what I've read here on multiple occasions, you need to be able to show proof (via photos usually) of the rashes, skin breakdown etc. Not just a one off either, they generally need multiple times skin breakdown has occurred to show it is a persistent issue that the usual treatments can't control. They generally won't approve these surgeries without "medical necessity",  and that's a worldwide issue when it comes to abdominoplasty. In Australia (where I live), they are at least coming around to allowing psychological distress to be part of a medical necessity claim as long as your insurer covers this procedure....many exclude it from cover though.

 

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  • 2 months later...

I was denied several times.  My surgeon's office told me this week that they submitted the request in four segments, three have been approved and they expect the fourth to be approved.  (I sure hope so.)

I had letters from my primary care and bariatric physician's stating that, in their opinions, the removal was medically necessary.  Both of them detailed skin infections they had treated and other concerns.  I gathered copies of doctor's notes from six other doctors who treated skin infections in the past.  I sent those copies in with the request as well.  I wrote a letter detailing my weight loss and the issues the skin causes.  I detailed how the skin interfered with activities of daily living.  I included humiliating pictures as well.  My surgeon included a letter of support for the procedures with the request.  I felt that I had provided everything that their requirements detailed.  What else could I possibly give them? ....  Denied.

My surgeon sent me a list of questions from the insurance company and asked if my primary care or bariatric physician could answer them for the insurance company.  None of them matched their published requirements.  "Have you reviewed the patient's medications to determine if they could be causing some of the problems?"  (One reason for rejection was "You have failed to demonstrate that analgesics have been unable to control the pain.")  "Can you demonstrate that you have attempted analgesic treatments unsuccessfully?" (Bouncing skin and infections).  A couple other questions that I don't remember right now.  

My bariatric doctor wrote a response explaining that he is an Endocrinologist and the prescribing physician and that he can confirm that there is no causation from my medications.  He also explained that analgesics are contra indicated because, due to my gastric bypass, I must avoid NSAIDS.  

He answered the other questions as well and reiterated that it was medically necessary.  I forwarded that letter to my surgeon and he sent it to the insurance company.  It was about two days later that they told me 3/4 had been approved.

So, I can't say there is any magic words or anything.  All I can say is that it is important to have your doctors' support and not to give up.

Good luck!!

-Mike-

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