Denied once, trying again!
I'm in California and have Blue Shield. I was denied for plastics in June 2008. After a crap load of frustration, I gave up and decided to try again this year.
This time around, I have documented skin dermatitis due to excessive skin. I also have a letter from my therapist. I have heard it helps to have a letter from my PCP, but her office is being reluctant to write a letter. My consult with the new surgeon is on July 27, so I'm running out of time. I just got the call from my PCP's office, saying "Well, what does Dr need to write a letter for, it's not up to her!" I specifically stated why I wanted a letter and discussed this with her the day of the visit. Now her staff is telling me she won't write a letter.
I'm so frustrated. I'm already nervous about getting denied again. Can anyone shed some light on how I can get her to write a letter, or provide a template that I can send her to see what I'm requesting?
Any help would be very appreciated.
Thank you,
Chelsea
This time around, I have documented skin dermatitis due to excessive skin. I also have a letter from my therapist. I have heard it helps to have a letter from my PCP, but her office is being reluctant to write a letter. My consult with the new surgeon is on July 27, so I'm running out of time. I just got the call from my PCP's office, saying "Well, what does Dr need to write a letter for, it's not up to her!" I specifically stated why I wanted a letter and discussed this with her the day of the visit. Now her staff is telling me she won't write a letter.
I'm so frustrated. I'm already nervous about getting denied again. Can anyone shed some light on how I can get her to write a letter, or provide a template that I can send her to see what I'm requesting?
Any help would be very appreciated.
Thank you,
Chelsea
Hi Chelsea. If you have been to the doctor and for the skin rashes/infections, and received treatments for them, then you are in good shape. No letter really needed from anybody other than the letter from the doc who is proposing to perform the procedure. Why a doc would hesitate to provide a letter for you, I have no idea !
Just as an example, here is what we write:
-------------------------------------------------
Dear INS company,
Please find the records of Ms. Chelsea attached. As you can see, she was seen December, January, and March by Dr. Smith for skin rashes and dermatitis of the ________ area(s). Each time, she was provided prescriptions for __________ which did not adequately control her skin problems (They already have a record of this BTW because they are paying for it). Her skin problems have been recurrent in spite of the treatments she has bene given.
I propose to remove the excess skin of the ________ to permanently remedy her skin infections, which have not responded to the above medications in spite of several months of treatment.
I feel that surgery is the only available option that will result in a permanent correction of this patients skin conditions, which have nagatively affected her quality of life.
----------------------------------------------------
The plan language of nearly all the maor carriers asks for this quite specifically, so I advise patients seeking coverage to "do what the plans want" in order to get coverage. Often there is confusion over what the term "documentation" means, and that does not refer to a letter alone. They want office visits, prescriptions, and any other proof that you went to the doc for your skin issues.
Hope this helps and good luck,
Dr. L.
Just as an example, here is what we write:
-------------------------------------------------
Dear INS company,
Please find the records of Ms. Chelsea attached. As you can see, she was seen December, January, and March by Dr. Smith for skin rashes and dermatitis of the ________ area(s). Each time, she was provided prescriptions for __________ which did not adequately control her skin problems (They already have a record of this BTW because they are paying for it). Her skin problems have been recurrent in spite of the treatments she has bene given.
I propose to remove the excess skin of the ________ to permanently remedy her skin infections, which have not responded to the above medications in spite of several months of treatment.
I feel that surgery is the only available option that will result in a permanent correction of this patients skin conditions, which have nagatively affected her quality of life.
----------------------------------------------------
The plan language of nearly all the maor carriers asks for this quite specifically, so I advise patients seeking coverage to "do what the plans want" in order to get coverage. Often there is confusion over what the term "documentation" means, and that does not refer to a letter alone. They want office visits, prescriptions, and any other proof that you went to the doc for your skin issues.
Hope this helps and good luck,
Dr. L.
John LoMonaco, M.D., F.A.C.S.
Plastic Surgery
Houston, Texas
www.DrLoMonaco.com
www.BodyLiftHouston.com
Plastic Surgery
Houston, Texas
www.DrLoMonaco.com
www.BodyLiftHouston.com
Hi Chelsea,
I am in CA also, but I don't have BS. I was also denied plastics when the ps put in the request. I also had a very large hernia that needed to be repaired and that was approved the first time around. Once I got the denial letter for the plastics I call the ps office and asked them for the CPT codes they were trying to get approved. Then I called my insurance office and asked what information they needed to approve the following codes. They gave me the information, which did include a letter from my primary doc. who has treated me for rashed for four years. I also included a copy of the first doc. notes when I went in the first time for the rash. I faxed everything to them (always get the name of a real contact person) and they called me two days later letting me know that everything was approved. They paid for my hernia repair and a complete tt. In my case I think that it helped that I needed a hernia repair.
Hope this helps - good luck.
Mary
I am in CA also, but I don't have BS. I was also denied plastics when the ps put in the request. I also had a very large hernia that needed to be repaired and that was approved the first time around. Once I got the denial letter for the plastics I call the ps office and asked them for the CPT codes they were trying to get approved. Then I called my insurance office and asked what information they needed to approve the following codes. They gave me the information, which did include a letter from my primary doc. who has treated me for rashed for four years. I also included a copy of the first doc. notes when I went in the first time for the rash. I faxed everything to them (always get the name of a real contact person) and they called me two days later letting me know that everything was approved. They paid for my hernia repair and a complete tt. In my case I think that it helped that I needed a hernia repair.
Hope this helps - good luck.
Mary
Thank you everyone for your support. I have my appointment this afternoon and I'm incredibly nervous. Instead of asking the surgeon to fax all my documentation, I will do it on my own to ensure it gets to the correct place.
Can anyone suggest how long after my consult I should call to get a reference #/contact name? I was denied within a week the last time I tried...
Can anyone suggest how long after my consult I should call to get a reference #/contact name? I was denied within a week the last time I tried...
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