Plastics Question

I talked to my insurance company about coverage for skin removal (tummy tuck,etc). They said it would be covered if medically necessary - a letter from my Dr. would be needed.

I forgot to ask which Dr.  - is it my Family Doctor, the Surgeon that did my Lap Band, or the Plastic Surgeon, or all three?? 

Hoping to get plastics sometime next year!! 

From what I've heard it would be the PS and they have to take a pic to send in to the ins. co. also,

Actually form what I have studied the more evidence the better. If all of them would be willing to do it I would go that route. Also, photos are a good thing. K

July15th, 2011
Attention Appeals & Grievances Unit
YOUR INS.COMPANY
P.O. BOX 1234
CITY,STATE. ZIPCODE


Re: YOUR NAME
Member ID # XXXXXXXX
Health Plan XXXXXX
Group # XXXX
Authorization Request Reference # 000XXXXXXXXXX


Dear Appeals and Grievances Unit,

Please accept this letter as YOUR NAME appeal to YOUR INS COMPANY decision to deny coverage for:

• a) 15830 Abdominoplasty , Excision, excessive skin and subcutaneous tissue (including lipectomy) ; 15847 Excision, excessive skin and subcutaneous tissue, abdomen includes umbilical transportation and fascial  placation.
• b) 15832-50 Excision excessive skin/subcutaneous tissue of bilateral thighs.
• c) 15833-50 Excision excessive skin/subcutaneous tissue of bilateral leg.
• d) 15834-50 Excision excessive skin/subcutaneous tissue of bilateral hip.
• e) 15835-50 Excision excessive skin/subcutaneous tissue of bilateral buttock.

• f)  15836-50 Excision excessive skin/subcutaneous tissue of bilateral arms.
• g) 15879-50 Suction assisted lipectomy of bilateral legs.

It is my understanding that based on YOUR INS COMPANY letter of denial dated DATE OF DENIAL that this procedure has been denied because: Lack of Medical Necessity as well as YOUR PLASTIC SURGEON is not a contracted provider with YOUR INS COMPANY.


As you know, YOUR NAME was diagnosed with Morbid Obesity on XX/XX/XXXX. ICD9 CODE XXXXXXXXXX Currently YOUR PLASTIC SURGEON believes that YOUR NAME will significantly benefit from:

a) 15830 Abdominoplasty , Excision, excessive skin and subcutaneous tissue
   (including lipectomy) ; 15847 Excision, excessive skin and subcutaneous tissue,
   abdomen includes umbilical transportation and fascial  placation.
b) 15832-50 Excision excessive skin/subcutaneous tissue of bilateral thighs.
c) 15833-50 Excision excessive skin/subcutaneous tissue of bilateral leg.
d) 15834-50 Excision excessive skin/subcutaneous tissue of bilateral hip.
e) 15835-50 Excision excessive skin/subcutaneous tissue of bilateral buttock.
f)  15836-50 Excision excessive skin/subcutaneous tissue of bilateral arms.
g) 15879-50 Suction assisted lipectomy of bilateral legs.

Please see the enclosed letter from YOUR PLASTIC  SURGEON that discusses YOUR NAME medical history in more detail.

YOUR NAME believes that you did not have all the necessary information at the time of the initial review. YOUR NAME has also included with this letter , a letter from YOUR PLASTIC SURGEON of,
" You stab em we slab em plastic surgery center" . YOUR PLASTIC SURGEON is a specialist in plastic surgery for (WLS) weight loss surgery patients. His letter discusses the procedure(s) in more detail. Also included are medical records, and journal articles in support of the importance of weight loss and relief from chronic back pain.

YOUR NAME has been a member of YOUR INS since January xxth, xxxx During that time YOUR NAME has participated within the network of physicians listed by the plan. At this time there is not a physician within the network who has extensive knowledge in these procedure(s) regarding Weight Loss Surgery patient's.

YOUR NAME has also included a letter from Dr. Feel Good, ( My pain management doctor )

Dr. Feel Good has been YOUR NAME Pain Management doctor since xx/xx/xxxx and has stated that YOUR NAME is not a spine surgical candidate and  has not improved with conservative therapy and has exhausted all treatments thus far.

 Dr. Feel Good also states that surgical correction for her center of gravity issue should be considered. Dr. Feel Good states that YOUR NAME has lost a great deal of weight and continues to have excessive skin that is contributing to her problems with her center of gravity that is in effect causing her more pain. and that she should be considered for this surgery to correct this issue and as a result improve her pain.

Based on this information YOUR NAME is asking that you reconsider your previous decision and allow coverage for the procedure(s) YOUR PLASTIC  SURGEON outlines in his letter. Should you require additional information , please do not hesitate to contact YOUR NAME.at 1-555-555-5555 or
1-777-777-7777. YOUR NAME will look forward to hearing from you in the near future.

Sincerely
YOUR NAME

great stuff!!

It's easier in California because by law they have to put you back to normal. This works for the panniculectomy, breast reduction, and some other things that are not coming to mind t this moment.

good luck

Wow, thanks so much!!!

Tooty, the letter has to come from the PS, the insurance company may also request pictures showing the hanging skin as well as documentation showing you may have rashes or any type of skin irritation. Hope this info helps. I'm having my panniculectomy on Aug 3 and it took about a week and a half for my approval.

K.Free