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Personal Choice Blue Cross/Sheild Pays for Reconstructive After WLS ...WHAT??????

Spedteacher59
on 6/30/10 10:34 am - Levittown, PA
So, I got a call from Barix today asking how I am doing after my 1 year WLS surgery...blah blah. Then she asks me have I thought about reconstructive surgery. I said, "yes, but my insurance won't cover it right?" She says, "Oh you have Personal Choice...they are very good about covering the surgery. They usually cover a tummy tuck and a breast lift." I say, "Oh my gosh really!" She says, "Well it depends on how much hanging skin you have...but yeah. Ask Dr. Boe to check you and discuss it when you go in for your one year check up." Well my one year check up is on July 15th and I have plenty of hanging skin! Can this really be possible? I really didn't think insurance would cover what I believe they would think of as cosmetic surgery. Has anyone ever heard of this w/o having significant skin abcess etc. issues?? Also, if you had it done how bad is the pain factor?

Thanks a bunch,
Kathy
dhaworth
on 6/30/10 10:55 am
I have Blue Cross and my TT was 100% covered, a breast lift was not covered, but a reduction would have been.  I didn't have much hanging skin at all, I had lost 100 lbs and that was the only criteria I had to meet.

Good luck to you!!!
Spedteacher59
on 7/2/10 6:47 am - Levittown, PA
Thanks....I could live with just my tummy being covered. It seems from the responses I have gotten they really pick and chose who and what they will cover with no real rhyme or reason.
Kathy
Jupiter6
on 6/30/10 11:23 am - Near Media, Pa- South of Philly, NJ
I have the same plan as you do (BC BS PersChoice) and had excessive piles of skin after a 220 pound loss, with huge weeping rashes, festering sores and three years of treatment and photos documenting all of it in graphic detail, and still NONE of it was covered. I appealed twice, and nada. I had three peer to peer consults and letters from three doctors explaining the medical necessity.

None. Zero. Zilch. Nada.

Pain factor? You can't even imagine. Seriously.

 "Oh sweet and sour Jesus, that is GOOD!" - Stephen Colbert  Lap RNY 7/07-- Lap Gallbladder 5/08--  
     Emergency Bowel Repair
6/08 -Dr. Meilahn, Temple U.  
 Upper and Lower Bleph/Lower Face Lift 
12/08 
     Fraxel Repair 2/09-- Lower Bleph Re-Do 5/09  -Dr. Pontell, Media PA  Mastopexy/Massive 
     Brachioplasty/ Extended Abdominoplasty 
(plus Mons Lift and Upper Leg lift) / Hernia Repair
      6/24/09 ---Butt Lift and Lateral Thighplasty Scheduled 7/6/10
 - Dr. Ivor Kaplan VA Beach
      
Total Cost: $33,500   Start wt: 368   RNY wt: 300  Goal wt: 150   Current wt: 148.2  BMI: 24.7

Spedteacher59
on 7/2/10 6:45 am - Levittown, PA
Sorry to hear they didn't cover you............unbelievable with all the problems you had. I hope I have better luck because I can't afford to do anything at all if it's not covered.
Kathy
Lisa R.
on 6/30/10 11:53 am - Cleveland, OH
For them make the broad statement "they're pretty good about covering..." is very misleading.  An inusrance company writes policies for companies based on what the company (your employer) wants to cover.  The more that's included, the higher the premiums.  So it really depends on how the policy is written for your company.

Contact your HR rep for a copy of your policy if you don't have one.

As for pain, that depends on the pain tolerance of the individual.  For me the LBL wasn't as difficult as the thighs.  For others, it's the opposite.
RNY:  10/11/2001 PS:  May 28, 2010: Circumferential body lift with gluteal augmentation and brachioplasty & thoracoplasty June 25, 2010: Bilateral breast augmentation with mastopexy and medial thigh lift

    
Terrence_CA
on 7/1/10 8:21 pm
I have Blue Cross PPO insurance. My dooctor submitted for a circumferencial body lift, medial thigh lift, breast lift, torso lift, and an arm lift. The only thing they decided to cover was my arms of all things. I am going to appeal the body lift and thigh lift and hope they cover at least one. Hopefully it will be the body lift as that is the most expensive lol.
Gastric Bypass 8/14/08
SW: 513 lbs
CW: 250 lbs




jastypes
on 7/21/14 12:22 pm - Croydon, PA

Hey, Kathy, let me know how it goes.  I'm a Barix baby too.  I did go to a plastic surgery consult with Dr. Lam.  He believed that my arms would not be covered, and there were specific requirements for the tummy tuck in my Personal Choice policy.  I believe it was 6 months of documented rashes, or something similar. 

 


Blessings, Jill

WLS 5/31/07.  Maintaining a weight loss of 141 pounds and feeling amazing!

MercyQ
on 7/21/14 12:54 pm - FL

Hi Kathy, it’s not so much what insurance you have, but what your specific plan covers, regardless of the company, there is a wide range of coverage plans out there, even within the same company. If you have insurance through your employer and it is “self-funded”, meaning the insurance company “manages” the plan for your employer, your employer can design just about any plan they want. My advice is to request the official plan coverage for your plan, they usually have it on line, and read the fine print; there are often loopholes that can be explored. If a plan covers weight loss surgery for health reasons, very often they will also cover “reconstructive surgery”, there is no plan out there that will cover cosmetic surgery, a play on words, I know. The plastic surgeon you choose needs to clearly document all the issues supported by your PCP’s documentation, it’s also important that he has experience dealing with weight loss patients and the submission of such claims; we are a different “animal” as they say.

There is still a chance, as I see here by some posters that it won’t be covered, but here is what happened to me. My doctor submitted for a Breast reduction, not a Breast Lift, they must remove at least 400 grams, my surgeon only ended up removing 200 grams, somehow my insurance covered it upon submission. My surgeon submitted a panniculectomy, not a tummy tuck, the latter tightens the stomach muscles, the first does not, again, I agreed to pay the difference, but my insurance ended up paying for it upon submission and I ended up with a credit after paying. I also had a few procedures together, so the hospital and anesthesia would be covered, the only potential for non-payment, was the Tummy Tuck, but in the end it was all covered. I also had my top lids done (dropping skin/visual impairment) I was referred to have a vision test and it was also covered. Do your homework and check the Plastics Forum, Good Luck!

MercyQ. This is the Beginning of the Rest of my Life!!
  

pineview01
on 7/22/14 8:34 pm - Davison, MI

You really did do your homework 

BAND REMOVED 9-4-12-fought insurance to get sleeve and won!  Sleeved 1/22/13!  At third goal and "normal"

Spedteacher59
on 7/2/10 6:42 am - Levittown, PA
How odd is that???? Just the arm lift??? You would think that one would be the last they would cover. Good luck on your appeal.
Kathy