Question:
Anyone have BC/BS PPO Pay for Abdominoplasty for 2005?
4 yr post-op RNY, still trying to get BCBS to pay for abdominoplasty, they've said I don't meet their medical criteria for the surgery, does anyone know what their medical criteria is? When I lay on my side it looks like I have a watermellon pulling away from my waist and hips, when I bend over it looks like an utter without teets, my puffy panni flows onto my upper thigh about 4". I asked my doc why this is as I thought I had no muscle holding in my abdominal organs. He said some post-op's have loose hanging skin and others like myself have about 1" of fat underneath the skin that won't go away with exercise or diet, he said the only way to get rid of it is to have an abdominoplasty where they could remove that layer of fat. I'm working on letters of med ned from my RNY surgeon, a neurosurgeon who has performed 2 recent back surgeries, an anesthesiologist who is treating lumbar disc compression by pain mgnt, a psychologist as I feel physically un-attractive, a nutrictionist, my primary doc who prescribes cream for my panni rash during hot weather days and pictures. Need all the help I can get, anyone have med ned letters willing to share for 2005? Any web sites out there which offer assistance re: how to get approved? Again my big question? is it more difficult to get TT approval from BCBS for 2005 than the previous years? Any info greatly appreciated. Thank you for your support. — Barbara M. (posted on March 29, 2005)
March 28, 2005
I had my abdominalplasty in August 2004. BCBS Community Blue PPO gave my
surgeon pre-approval because I had lost over 100 pounds and he also
submited photos and medical problems like yeast infections under the folds.
BCBS paid everything, but my $400 co-pay for the hospital. I am not sure
if they have changed the criteria for 2005, but you might want to call them
directly and ask what documentation you need. Good luck.
— ckreh
March 29, 2005
I also got coverage but again it was in 2004, but it was under a PPO plan.
I got full coverage for a full extended abdominoplasty done in 2 surgeries.
Not all skin involved could be removed in the first surgery due to my
waist being very anchored and not being able to pull all the excess skin
down and cut off like normal.
<p>I had similar issues as you. My approval was based on severe
degenerative disc disease in 4 discs in the low back. I never had any skin
issues. I also submitted with a letter from the Neurosurgeon and PS and
they did not approve. But in my denial letter it said that it appeared to
be cosmetic but they would agree to evaluate again after I was done losing
and that I should resubmit with an orthopedic evaluation and recommendation
and new pics. The one pic the PS sent was horrible and hardly readable. I
was ticked at first about needing the ortho eval but did it anyway.
Fortunately the ortho I saw was totally supportive and wrote a great letter
that said there was no question that removing the skin would help my back
condition. It would not fix it but would allow it to improve as much as
possible and also allow the stomach muscles to be tightened which also
factors into the back. He also reminded them that anti-inflammatories are
not an option as a PO and that I had been using epidural steroid injecitons
as well as oral steroids occassionally to deal with the problems since
about 1997. I also had the neurosurgeon write a more detailed letter
stating why he did not want to do surgery at this point. I then wrote my
own letter and in there clearly stated that I knew it would not fix things
but that it was a logical and cost effect way to manage this medical
condition and that the hope was that it would help me to totally avoid
surgery or at least delay it for many years. I then had my friend take
really good pics and I delivered it all to the local BCBS service center
and had approval the next day. Only in my letter did it mention the need
to have the surgery done in two stages. The PS's note made a slight
mention yet he never asked for approval that way. I got approval for both
stages and did not have to go back after the first operation and seek
approval for #2. Which is good, because truthfully it would have been a
lot harder to call that medically necessary versus cosmetic. It looked
very strange because it could not all be removed, but really did not affect
my back. It was clear that the first reviewer wanted to approve my request
but needed some more teeth to justify it. I have never had a denial letter
from BCBS lead me down the path to approval, like this one did. It might
help to take the same approach with an ortho eval. The bottom line is in
their mind if it's all neurologic then removing the skin won't help. They
wanted to know that something "mechanical" would be fixed or
significantly improved. An ortho is based on mechanics, so that is why
they wanted a letter from him stating that this would improve things. And
truthfully it has. My back is rarely an issue with me any more. If I do
too much standing then I can have some leg/foot numbness in my right leg
because of sciatic compression, but other than that I am soooo much better.
I hope some of this info can help you!
— zoedogcbr
March 29, 2005
in 2004 I got approval for a panniculectomy based on photos submitted by
the plastic surgeon. the only criteria that I know of was pannus covering
private area. I only had 1 minor yeast infection in my belly button that I
did not even go to the doctor with, treated my self over the counter with
monistat. I had to pay the balance to get the other stuff done. Everything
(pictures included) had to be submitted directly by the Dr. tho.
— **willow**
Click Here to Return