- HEALTH TRACKER
The Plan acknowledges that surgical procedures to remove redundant skin following weight loss from bariatric surgery may qualify for coverage as "reconstructive surgery" under Health and Safety Code section 1367.63 if the redundant skin constitutes abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumor or disease and the procedure is to either improve function or create a normal appearance, to the extent possible.9 The Plan also acknowledges that it will not deny authorization for such skin reduction procedures on the basis that morbid obesity is not a disease within the meaning of section 1367.63.
I'm not sure this is the end of it yet, however. The next fight is going to be about what "abnormal structure of the body" means.
When you are ready to submit for insurance coverage, you are going to need a letter of medical necessity to go with it, either from your PCP (if you need a referral and preauthorization to get to see the surgeon), or your surgeon. You should ask for the doctor who is preparing your LOMN to see a draft before it is sent, and then send it to me. A poor LOMN can screw you!
But there is a lot of work that needs to be done first. YOU need to write your own letter, detailing your medical history, BMI history, compliance with requirements for your first surgery, current problems, and why you need to have a revision. You also need to figure out if your insurance has limitations on (1) bariatric coverage at all; (2) coverage for revisions (many insurance companies have a "one-bariatric-surgery-per-lifetime" limitation); (3) restrictions on access to the DS, e.g., only for BMI >50. It is unlikely that an exclusion of bariatric surgery can be overcome, but the other two can. But if you have them, you need to address them UP FRONT and not just with a generic LOMN - but your PCP or surgeon won't do this for you - YOU need to provide this information for him in advance, via your letter, which you will provide to the doctor to help write his LOMN.