Hi there all,
It has been so long since I've posted here, but I've had a lot going on. I'm currently trying to get approved for panniculectomy and I am having no luck. Has anyone out there had success when their pannus does not hang below their pubic area? I have rashes all the time and keep getting denied. I am at my final 3rd party review appeal and I just want to show up guns blazing. I did not work this hard to be denied something medically necessary.
Thank you in advance!
Do you have a plan B lined up? You may have to self-pay even if it is medically necessary. See if there is a plastic surgery residency program near you. They provide services at a very reasonable cost.
Start saving now. Or make sure your credit score is good so you can get a loan.
Laura in Texas
51 years old; 5'7" tall; HW: 339 (BMI=53); CW: 140 (BMI=22)
RNY: 09-17-08 Dr. Garth Davis
brachioplasty: 12-18-09 Dr. Wainwright; lbl/bl: 06-28-11 Dr. LoMonaco
"If what you're doing doesn't work, change what you're doing - don't complain that it doesn't work."
my insurance did not cover any reconstructive surgery. Medically necessary or not. I saved and paid cash.
Hala. RNY 5/14/2008; Happy At Goal =HAG
"I can eat or do anything I want to - as long as I am willing to deal with the consequences"
"Failure is not falling down, It is not getting up once you fell... So pick yourself up, dust yourself off, and start all over again...."
Have you asked for a copy of their medically necessity criteria? Remember, insurance is a contract and medical necessity is only defined by their written criteria. Appeal based on the criteria, and detail how you meet it. Otherwise, you aren't likely to be successful. Also, make your appeal in person ( there is likely a committee that will review your case). I ran an appeal department for years, and chaired the appeals committee for many insurance companies over the years. Appearing in person, and an argument based on the written criteria, is likely to win. Good luck.
Height: 5'7". HW: 299, Program starting weight: 290, SW: 238, CW 138 - 12 pounds under goal!
Every plan I know of requires the skin to hang below the pubic area. I have links to the AETNA, Blue, and Cigna carriers on my webpage in the document "Tips for Getting insurance Approval."
Let me say that up until around 2012, I put up huge fights for insurance paying for surgery because the plan language defined deformities and medical necessity loosely.
They have wised up, and now strictly adhere to the criteria.