Just *****ing (Insurance)...

So Friday I come home to find that the plastic surgeon I consulted with sent the consultation fee through insurance.  It was denied.  I called the insurance and asked why - they told me it was a coding situation; they couldn't tell me the 'problem' with the coding situation, but based on the code, they couldn't pay it.

So I said, "Let's just cut to the chase - here's the deal.  Had WLS in December 2007, paid for it out of pocket because it's excluded from the policy (had the same insurance then, too.)  I've lost 200+ pounds, looking into PS - tell me about my insurance benefits."  Insurance customer rep tells me that because the need for plastic surgery is a result of WLS and they didn't cover the WLS, they are not going to cover any of the PS!  And of course if I have PS and there are complications, they won't cover complications either.  (This was the same for WLS - no complications knock on wood!)  Oh, but she said I could try to appeal it and cheerfully gave me the mailing address.

So a) if I had lost weight on my own, you would or wouldn't cover plastic surgery (this is a moot point as 1.  I did have WLS and 2. I could have never have lost 200+ lbs on my own but I just want to know the answer) and b) how PS for me NOT be considered reconstructive as I've never been a 'normal' body shape as an adult - would they have covered plastic surgery when I weighed 440 pounds???  As if any doctor would have touched that!!!! Oh it just burns my ass!

Any chance of fighting this?  I have another consult with a PS in Denver on May 29th that has lots of experience with larger patients and huge amounts of weight loss - his office said they have never had insurance pay for PS after WLS.  However, I thought, yeah, you probably don't fight very hard because it's more money in your pocket - why accept what the insurance will pay you when you can clear more by cash pays?  Yep, I'm cynical about right now.

Yes, I can probably pay for this out of pocket - it's called borrowing against my inheritance.  That's what I did for WLS.  However, I hate it.  I'll have all of it spent on being sliced and diced before it's even rightfully mine!!!!!!

***** ***** *****!
Jana

Fight the insurance company.  If you are having reconstructive surgery they shouldn't just disallow it simply because it is a result of your weight loss surgery.  And PS's would much rather have a self pay than an insurance patient so don't listen  to them either.

It is odd to have the insurance company pay for PS unless it is a panniculectomy and you have medical reasons why it is needing to be removed regardless of why the extra stomach is there.   Rashes, boils and yeast infections are the main reason why they will pay.   Back and shoulder pain can cause them to pay for a BL.   Start documenting and then submit a pre-determination.    Insurance companies will not pay if they believe it is cosmetic.

Most of us have been in this boat and end up paying out of pocket. 

Good Luck

Did you submit pictures (at least did the surgeon)?  Mine was denied at first, but I sent in a letter stating why it was not just cosmetic and was truly medically necessary, and they finally looked at the pictures...when they saw the pictures, I had my legs approved very quickly.  The excess skin and tissue on the backs and inside of my thighs cause balance issues....and is very painful if I try to jog as it pulls a lot.  I wrote in my letter how I am unable to ride a bike as it makes me wreck, and also how I am unable to hike and climb Pikes Peak....now I have never climbed Pikes Peak, but I have gone up to the half way point on the Inlcine...and yes I had issues, I almost fell several times due to my legs.  So can you file an appeal with something like I did?  Good luck, I hope it works for you!!!

From someone who works in the medical insurance industry...

BY ALL MEANS YES.....

Have your PS submit the pre-approval.... wait for the denial, send your own letter requesting a formal appeal by a review of the dr's peers (which means it will other PS's reviewing the request... ) with any extra information you  can provide, have your pcp and GBP surgeon also submit a letter and, if you see a phd have him/ her write a letter as well and attach all of those letters to your letter...

if it comes back denied again, you can submit an appeal to your local insurance commissoner for review.

I'm not knocking the customer service reps but... they do not have medical back grounds. their only stating 'typical' policy.... loosing 200+ lbs regardless of the reason.... is not 'typical'..

Good Luck !!!