Brachioplasty Appeal Denied

Doesn't meet criteria for medical neccessity.  So I then asked for the name of all the physicans who were a part of the decision. She put me on hold and came back with the friggin' name of MY surgeon...I said that's my surgeon if he made the decision I would be APPROVED!!!!   At least this customer service person was trying to be helpful, she remembered me, said everyone there was pulling for me, I said well OBVIOUSLY the ones making the decision aren't, and I asked if they had a problem with their vision??? For those of you who might have missed the month long rant....BCBS denied my bracioplasty, and have now denied my appeal. Here are the pictures as to why it's medically neccessary, add to that the doctor letters documenting a congential condition and 3 years of treatment for neck pain, antibiotic prescription. http://www.obesityhelp.com/photos/albumId,28100/uzone,photos /action,gallery/ I haven't really felt that spending to much more of my emotional energy on this. I couldn't even say anything more to my mom or Mom2 but "they denied me". I came home and got a glass of Diet Sunkist, put my bed buddy heat wrap on my neck and took a nap, I'm up now so I'm ready for Grey's Anatomy. Before leaving work I e-mail my contact at Oprah, I had a taped segment on a show in May 2005 that had Stacy Halprin on it, then I e-mail my benefits admin to ask if I HAD to do the 2nd appeal with BCBS or if I could skip it and appeal directly to my employer since I think my best chance is with them and I would rather not waste more time with the dumbass physicians at BCBS. Then I also e-mailed the local TV station that airs Oprah. I put my pictures in all the e-mails I sent, not attachments, c&p in the message so they can't miss them. My next step is to also have my PCP refer me to an ortho for the neck pain. Maybe BCBS will think twice about my case once they start getting yet another SPECIALIST bill for me!!!!

I have not read the original post so I am just going by what you wrote here and your pictures.  The pictures document that you have a lost of excess skin but the removal would be cosmetic if you did not have a medical condition, like rashes to support the claim.  Based on the denial, it sounds like that is what the insurance company is saying.  So, in addition to showing the excess skin you need to support the medical reason for the surgery with doctors notes showing rashes or other skin problems for typically three months or longer.  You should also save copies of your pescriptions.

Please don't take this wrong, as I am trying to help, but I would not take the approach of,  "look at this excess skin and how can they deny me" you should say, because of this excess skin I have the following medical conditions that are supported by XX visits to my doctor, my doctors notes and surgery recommendation as the only hope, and XX pescriptions that did work and here is the proof I had them filled and used them for the required three months (or however long the required time is by your insurance company).  If you do not have rash or skin issues push whatever medical condition the excess skin is causing. Bottom line is that the insurance company will only cover medically necessary and perhaps not that they don't care but will not cover unless you can prove medically necessary and the burden is on you to prove it. I was denied for RNY with Aetna but won on appeal.  I hope to get approved for a panni in the next few months and will be facing the same issues.  I have been doing a lot of research of this subject.

Jim Randall

To catch you up, I have a congential condition, lipedema, which is the main reason for the size of my arms and the fact that despite massive weight loss the size has not changed. I did in fact show documented skin rashes, pictures, doctor notes, and my prescription history that I printed off of my BCBS patient website. I also have documentaion of over 2 years of neck and shoulder pain, I have not had any other accident or injury that would cause the chronic pain. They HAVE all the information that you suggest I send them, they are just choosing to ignore it.