getting insurance to pay

After getting a bound intestine and having emergency surgery last summer and I am now the proud owner of a very large hernia.  When I went to my surgeon, he said that it needed to be repaired ASAP. He also asked if I ever thought about getting a TT.  My feeling has always been NO WAY if it means another surgery.  I don't care how bad my skin hangs down.  Now the surgeon said that I would heal better and have less chance of infection if I also got a TT with the hernia repair.  My insurance has approved the hernia repair, but has denied the TT saying that it is not medically necessary.

My doctor suggested that I appeal the decission.  Therefore, my question is "How do I get the insurance to approve the TT"?  The doctors office said to send in any documentation of my constant rash and just tell my personal story (clothes don't fit, people think that I am pregnant, etc.) 

Any other suggestion on getting approval?
Thanks!

I would right about the rashes and say it hurts when it hangs. clothes don't fit, it is hard to excercise with the skin flapping
 I wouldn't say about the pregnancy because that is cosmetic
Good Luck

Thanks to a few other OHers, I was recently made aware of the fact that part of the CA statute says that reconstructive surgery must be covered by insurance companies.

One of the OH members emailed me a template letter that she used.  If you send me your email address via PM, I can email you the template. I haven't submitted to insurance yet, so I cannot guarantee that the letter will work, but it's a darned good letter and I think it is worth a try.

Just send me a PM with your email addy and I will get it to you!

Best,

Cindy

California Health and Safety Code 1367.63:

 

1367.63. (a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, renewed, or delivered in this state on or after July 1,1999, shall cover reconstructive surgery, as defined in subdivision (c), that is necessary to achieve the purposes specified in paragraphs (1) or (2) of subdivision (c).  Nothing in this section shall be construed to require a plan to provide coverage for cosmetic surgery, as defined in subdivision (d).

   (b) No individual, other than a licensed physician competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for treatment pursuant to this section.  For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed individual, competent to evaluate the specific clinical issues involved in the care requested.

   (c) "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:

        (1) To improve function.

        (2) To create a normal appearance, to the extent possible.

   (d) "Cosmetic surgery" means surgery that is performed to alter or reshape normal structures of the body in order to improve appearance.

   (e) In interpreting the definition of reconstructive surgery, a health care service plan may utilize prior authorization and utilization review that may include, but need not be limited to, any of the following:

        (1) Denial of the proposed surgery if there is another more appropriate surgical procedure that will be approved for the enrollee.

        (2) Denial of the proposed surgery or surgeries if the procedure or procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, offer only a minimal improvement in the appearance of the enrollee.

        (3) Denial of payment for procedures performed without prior authorization.

        (4) For services provided under the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), denial of the proposed surgery if the procedure offers only a minimal improvement in the appearance of the enrollee, as may be defined in any regulations that may be promulgated by the State Department of Health Services.

Send the copy of your state's law on reconstructive surgery that Cindy is suggesting above.  Also include copies of any and all doctors' records regarding any skin problems you have experienced, hygiene issues, recurrring problems relating to the hanging tummy.  Just the fact that you have a hernia should also help - with letters of recommendations from your PCP saying that you are a good candidate for reconstructive surgery to remove a "large pendulous panniculus" which causes additional strain to your abdominal wall; exacerbating the already damaged area (the hernia).  You have to convince the insurance company that the TT is not cosmetic and is medically necessary.  Any medical documentation, letters of recommendation, pictures, medical records, etc. will better your chances of overturning the denial.  Good luck.