Seriously About To Give Up

The goal to getting any insurance to consider and possibly cover a procedure they deem "cosmetic" is to have letter(s) of medical necessity from your Doctors that outline the issues you experience with the Pannus being so large.   Back pain, cellulitis, pressure sores, etc.  If you have any rashes, you need to take photos, so those can accompany the letter.   They have to prove to the insurance carrier that this is MEDICALLY NECESSARY and not for vanity reasons.   

So, this is where I would suggest you start.   Just calling your insurance carrier and asking them if they will cover a procedure does not get you a clear answer, because it does not clearly demonstrate to them that there is a medical need.  

This is what I would suggest to you:  

1. Contact your PCP and ask him to start a letter of Medical Necessity for a Panniculectomy.  
2. Contact your Orthopedist and the two surgeons, request the same.   
3. Make sure that each physician includes office or hospital notes showing where you have had issues with Cellulitis and pressure sores due to the pannus being so large.   
4. Take photos of your pannus especially if you have cellulitis currently.  This will help to demonstrate to a claims adjuster the medical need for the surgery.  
5. Continue to document any and all issues you experience due to the large pannus by seeing your physician as needed to document.  

The above is going to take time, so don't expect this to be something you can accomplish in a matter of days or weeks.   Depending on how much documentation they have on you and the problems attributed to the pannus, it could be sooner, but overall you are probably looking at a good 3-6 month time frame of actually being able to get all information submitted to the insurance carrier for review.  

Just hang in there and don't give up.   I know how frustrating it can be, but you can do this!   You just need to show them the medical necessity for the procedure.  

Best of luck! Be sure to keep us updated! 

Have you considered applying for disability? I sounds as If you would qualify. I would suggest using a lawyer that specializes in such cases. They typically don't require any money up front and can legally only take a specific percent of your settlement . Once your on disability after a specific amount of time you qualify for Medicare. Traditional Medicare, covers bariatric surgery and many other medically necessary procedures by many providers. It sounds like you could really use the assistance . 

You have to be on Social Security Disability for 2 years before you qualify for Medicare.

Hi Lodie!  I have applied and been denied.  Currently waiting on my appeal hearing.

Weight Loss Surgery foundation of America has a grant program where they help people pay for Bariatric  surgery. You should consider looking into it.

Thank you for the reply!  I will definitely check it out!

First of all thank you all for your tremendous ideas and support.  I have tried to respond to each one of you, but if I missed someone I am sorry.  I am still not happy with my situation, but I wanted to give everyone an update.  I spent most of the day on the phone with a newly assigned case manager from the insurance company and several of her "referrals" nutritionist, quality of life specialist, etc.  (behavioral health and mental health is still pending).  Here is what I have learned.  The INSURANCE company does pay for this procedure and for bariatric surgery regurally however - my husband's company's plan does NOT, so therefore my problem is with his employer not the insurance company.  My case manager is just as frustrated with this as I am.  I have saved and prepared all of the resources offered in these messages and I just have to get someone to print them for me - THANK YOU!  My case recommended that I go to human resources at my husband's company (who makes the decisions) with pictures and documentation and fight myself.  Also, my doctor has requested a "peer-to-peer conference" with the insurance company's medical director who can override the employer plan and pay.  My attorney and I are still working on my Social Security appeal (I don't qualify for SSI because my husband has a 401k,so  am trying to get what I paid in).  I also have another attorney waiting in the wings if the peer to peer doesn't work, that wants to sue my husbands employer.  I am VERY hesitant to do that because he has been there a little over 21 years and it would effectually end his career.  Anyway, again... THANK YOU for all of the support.  I will update when I know more.  May God Bless you all.

I'm sorry surgery isn't covered by your insurance. You can make an appeal to your husband's employer to ask them to add that coverage, but they would have to add it for every other employee as well. And depending on how many employees they have, it can be extremely expensive. I doubt very much they will do it.

Every year employers are dropping coverage for WLS because of the expense. There is no requirement for them to cover WLS, so they have no obligation. You are free to file a lawsuit, but you will certainly lose. Use the money you will have to pay your lawyer to self pay for surgery.

Think about car insurance. Here, we are required to pay for personal injury coverage, but not collision. If I choose not to pay extra for collision coverage, I will not be covered if I wreck the vehicle. I could sue them, but if the coverage isn't paid for, I'm out of luck.

I hope you find a way to get surgery, but I think you are at a dead end with your husband's employer.

Thanks Grim, I sort of feel the same way about the lawsuit.  The attorney is willing to put in writing he is doing it pro bono, but still and all I agree with you on many levels.  I am just praying for SOMETHING