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Help with Insurance Approval for Panniculectomy

QueenB98059
on 3/22/12 10:13 am - RENTON, WA
I am getting ready to write a 2nd letter to my insurance company to try and have them approve a panniculectory adbominoplasty.  The first denial letter says that "it does not show the I meet the criteria of medical necessity. And the documentation does noot show that I have a functional imparement caused by the excess abdominal skin or that this procedure would restore function." Since my bariatric surgery two years ago I've lost over 100 lbs. The excess skin and weight is causing me back pain and lower breasts pain. I know you all know what I'm talking about. I'm taking at least 6 pain medication per day.

What "wording" did your plastic surgeon use in order to get insurance to approve this surgery. Any assistance is really, truly, appreciated.

Sincerely,
Queenie
Valsdetermined2lose
on 3/22/12 11:47 am
iNSURANCE didnt a.pprove mine , i had to self pay but we were going to use loose hanging skin which i got rashes under skin and caused a yeast infection. I had to use creams and powders to control. Stable weight for 6 months.
 HW-267-SW-253-CW-167 I LOVE MY SLEEVE!!!
      
      
        

Tonya1263
on 3/22/12 4:03 pm
Not sure what kind of insurance you have but I have Aetna.  I can get on their web site and get what they call a "Clinical Policy Bulletin" that describes in medical terms exactly what the criteria is for them to cover any particular treatment.  I have gotten CPB for the WLS, for my gall bladder removal, for the panniculectomy, and abdomniplasty.  If you call your insurance rep they might be able to send/fax you there version of this document. Since you (or someone) is paying for this insurance they have to have in writing somewhere what the policy is. You can't effectively argue that you meet their criteria unless you know what the criteria are.   
My insurance considers abdomniplasty to be cosmetic and will not cover it at all.  The criteria for the panniculectomy; however, was detailed and specific.
  I made an appointment and went through it with my PCP (it's in medicalese).  Their criteria included how big it was and that it caused repeated rashes that had been treated for at least 6 months without results.  We then began documenting via photos and clinical visit notes that the pannus was larger than they required and that I had completed over 6 months of treatment with antibiotics and anit-fugal powders and it still recurred.   
Tonya