Question:
PS Dr. said I won't get anything covered. Should I try anyway?
My PS Dr. said that I don't have enough skin to qualify for Aetna PPO to pay for a TT or a Breastlift. He said they will take one look at my pictures and deny me. The thing is, I see people who have about the same or less skin than me get approval by Aetna. Should I tell him I want to try anyway and see what happens? Should I take his word for it? I really like him and have seen his work on alot of people I know. The charge for the TT, breastlift and arms is $18,630.00 including hospital costs, etc. My Dh wants me to have it done but the money is scaring him and he wants me to wait. Of course, I don't want to. — Kris T. (posted on October 31, 2002)
October 31, 2002
I think you should keep trying! I was denied the first time i went to a PS.
It depends on how it is written up. If he doesn't want to help find another
PS that would help you. Thant is what I did. I had surgery this past
April. I believe where there is a will there is a way.
— Sharon T.
October 31, 2002
i also think you should keep trying. dr's get less money if ins covers it
so they would rather have self paying patients. that also seems quite high
for self pay,,,here in fla all that would run around 10,000.
— JENNIFER A.
October 31, 2002
I have BCBS PPO, and my PS said same thing! I have a hernia that needed
attention and decided to just check out my options.
The PS Dr. kept saying during my appt that they weren't going to cover an
abdomoplasty (SP), but I asked him to please submit it.
My DH said that we could go into debt if I really wanted it done. The out
of pocket cost of doing the abdomplasty would have been $4,200.00,
if done at the same time as the hernia repair. On the way home I had
decided if insurance didn't pay I wasn't going to go into debt for the
repair! WELL less than a week later I had BCBS approval on paper in my
hands!!!
I will have it all done on 11/08/02! All covered! Why not just submit it?
You've worked so hard! My numbers may have been what cinched it for me,
I'm down 145lbs from the start of the entire process! Good Luck...and go
for it!
— Peggy N.
October 31, 2002
I have BCBS PPO, and my PS said same thing! I have a hernia that needed
attention and decided to just check out my options.
The PS Dr. kept saying during my appt that they weren't going to cover an
abdomoplasty (SP), but I asked him to please submit it.
My DH said that we could go into debt if I really wanted it done. The out
of pocket cost of doing the abdomplasty would have been $4,200.00,
if done at the same time as the hernia repair. On the way home I had
decided if insurance didn't pay I wasn't going to go into debt for the
repair! WELL less than a week later I had BCBS approval on paper in my
hands!!!
I will have it all done on 11/08/02! All covered! Why not just submit it?
You've worked so hard! My numbers may have been what cinched it for me,
I'm down 145lbs from the start of the entire process! Good Luck...and go
for it!
— Peggy N.
October 31, 2002
Yes, you should always try! If you want it, don't take the PS word for it.
He doesn't have to carry it around. You go girl! Good luck! Let us know
if it is covered ok? I have BC/BS Federal and BC/BS of Illinois. I want
to drop one of them and trying to decide which one. Both are PPO's.
Anybody have any suggestions on which to keep? Thanks!
— Mylou52
November 1, 2002
go to aetna's web page aetna.com. if you go to all of their policies, you
can determine for yourself if you meet thier criteria. Look under
abdominoplasty, and breast reduction. IF you only want a breast lift, it
doesn't look too good for you, sorry. Good Luck. I am trying ot get auth
through them also!!
— Vicki L.
November 2, 2002
I was denied by Aetna for TT and breast lift/reduction at 12 months
post-op,started at 266 and 5 ft 4 inches. I presently weigh 148. I thought
we had lots of good info for Aetna, but was still denied. They have
certainly tightened up on approving WLS in general in the last year and as
a result, I think on PS also. But, I have seen some folks on this site who
"looked" similar to me who got approved. I think it greatly
depends on the surgeon's expertise in documentation and using the proper
lingo for Aetna. The two biggies are if you have rashes from your panni
that can't be cleared with meds...it seems that it is not enough to just
have pics of various rashes or that it hangs to a certain point. It has to
hang AND cause a medical issue with rashes. I did not appeal at 12 months,
but I may re-sumbit in a few months. Wanted to wait and see how much more I
can lose and tighten up through exercise. Bottom line, I think we shouldn't
try until 18 months or so post-op to get our best shot at aprroval as the
loss will have leveled off by then. I also think you need, not only an
experienced plastic surgeon, but one who is very experienced in getting
approvals for post WLS patients. Keep us posted on your status!
— Molly S.
November 5, 2002
A plastic surgeon is ALWAYS going to tell you that insurance won't cover
anything. I've seen some VERY pitiful letters of medical necessity for
surgeries written by them because if insurance won't cover it, you will
still pay the ENTIRE cost yourself to have it done. If the insurance does
cover it and the doctor is in the PPO he will accept a GREATLY reduced fee
for his work (needless to say, he doesn't want that). I would have him
submit a letter of medical necessity, get your PCP to do the same and then
YOU submit a letter telling all the problems your having with doing
"normal" things. Be sure to send in pictures (stand sideways,
grab your stomach and pull it out as far as you can - this shows the
insurance company how much excess skin you truly have). With these letters
and pictures, you stand a better chance of getting approved. Good luck!!
— Patty H.
February 7, 2004
Get another PS that will submit the letter for you. Once they deny, you can
always appeal but DON'T GIVE UP!I was denied twice for abdominalplasty but
guess what!I won on appeal and they approved my breast lift! Don't give
up!email me for copy of appeal letter* [email protected]
— walkerl35
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