Appeal?

I work for an insurance company, so I am assuming that my plan is self funded.  Unfortunately, I do not know much about health insurance, as I work primarily with the commercial side of insurance.  Anyhow, I am confused about how this process works.  I submitted a pre-determination letter for surgery that was denied.  I appealed the decision and was denied again.  Now, United HealthCare is telling me that if I appeal again, that my employer will be the one to make the final decision.  I have 180 days to file my second level grievance.  The plastic surgeon did not submit a lot of information.  In her letter, she stated this patient has a pannus that covers her pubic region, intrego, yeast in her folds of redundant skin, and back pain.  So, I am recommending pannilectomy, brachioplasty, and pain pump.  Her pre-determination letter was exactly 3 sentences.   So, I would like to see another plastic surgeon that can write a more compelling argument as to why I need reconstructive surgery.  Addiontally, I would like to provide notes from my chiropractor and dermatologist.  My question is, if I file my second level grievance and it is also denied do I then bar myself from ever receiving those procedures?   If a different surgeon submits a pre-determination letter is that a new claim or will they automatically consider that my third appeal?   I am concerned because I don't want to go to plastic surgeon B and have them submit another 1 paragraph pre-determination letter on my behalf and then make me completely miss out on my opportunity for surgery.  But, I also don't want to go into plastic surgeon B's office with 2 denial letters from UHC and expect for them to help me undo what plastic surgeon A has done.   Also, if I am denied upon my 2nd appeal, in January of 2008 can I start over or will I be barred for asking for those services for the life of my policy? Last question: If I do exhaust all attempts with UHC and switch to BCBS during open enrollment, will they consider my redundant skin a pre-existing condition?  And, if they do, will that bar me from those services under a new insurance carrier? If anyone knows where I can find these answers, please let me know.

Hi,  I had the same thing happen to me (not for plastics though).  I was denied for surgery and submited both appeals and was denied on my third appeal  by my employer( i work for insurance company and we are self insured). I was advised that I would just need to resubmit a new predetermination claim through Aetna and it would be reviewed as long as the procedure is still covered under your insurance policy.  I have resubmitted and now I am just waiting.  HOpe this helps, you should be able to resubmit! Good luck