Guidance/Suggestions Please!

Good Evening,

I am 14 months out from RNY and down about 220lbs (10 from goal). I had a plastic surgery consult and following my exam my surgeon stated "I don't see how insurance could deny having the panni removed., you have one of the most extreme cases I've seen. I have documented rashes and had surgery for a skin infection last month.

I was devastated this week to find that my employer has excluded skin removal (even when medically necessary). So appealing through insurance is a mute point. My employer fully paid for my RNY and our company has huge incentives (or huge premium penalties) for having a BMI over 30).

Because of my surgery I went from a 57 BMI to my current 26 and it seems inconceivable to me that they would pay for gastric bypass but not the reconstructive skin removal. I am not giving up without trying to appeal to my employer to include this in the coverage. Goal achieved and I no longer have any of my co-morbities, but this is the final step in the process. I am suffering lower back pain, difficulty exercising, chronic painful, stinky rashes with a host of body issues, etc. My insurance paid approx $7000 in December for the skin infection surgery already.

I am looking for guidance, sample letters, or ideas on how to appeal this effectively through my employer. I really appreciate your time and any insight into this issue. Thank you!

I don't have any insights into helping you to get your insurance pay for your plastics...but I totally agree with what you are saying.   I lost 160 with my sleeve and another 15 with plastics so far.  Before my plastics I did TONS of exercise, but some things were impossible to do, such as simple jumping jacks or jump rope! I had so much belly hanging it pulled and HURT with every jump!  I run, lift weights, do yoga and pilates...but nothing would get rid of it.  I *HAD* to have plastic surgery...and I think it's ridiculous that insurance companies won't cover it when it's so OBVIOUSLY needed so that I can maintain my new found good health!  Good luck to you and your fight!

Document, document, document and keep the running tally of the cost of treating the skin infections.  Take pictures when the infection is particularly bad!  Keep a journal of when you experience pain, rash, infection, inability to perform a task due to the panni.  Having done all of this, you may still get denied because if your employer line itemed it out of their insurance policy, it is really the employer you are convincing, not the insurance company.  This means one of the executives at your company at some point had someone complain that the company is "paying for cosmetic surgery".  Without researching or knowing the real details, they probably thought this was the way to ensure the company would never pay for plastics again.  It might mean finding out from HR who makes these decisions in your company and petitioning them directily with your pictures, journal and receipts to prove that it was a bad blanket decision, that it is costing the company more money than the skin removal and causing their employees a lot of discomfort.  Most executives have no idea how sever a panni can be, how many people do you know that have actually seen a 20 lb panni in their life?  I would be not many.  It's hard to understand the repercussions of your decisions unless some one shows you the reality of the situation.  Good luck!!!  And, please, keep us informed, I hope you knock their socks off :)  Robin

Here is a link to Dr. LoMonaco's site. He has a section on insurance and some great tips along with a sample letter.

Hope this helps and good luck!

http://www.drlomonaco.com/tips-on-getting-insurance-for-plastic-surgery.shtml

I am so sorry that you're going through this! And to think that this is something that is seriously something that is causing you pain and discomfort - NOT an issue of "looks" or vanity - and your employer/insurance company won't cover it. I am so sorry :( 
I haven't fought this battle yet as I'm still working on losing a good twenty to thirty pounds, but I am definitely going to be taking notes on your experience. I second another reply with the advice being "document document document!" ... the more evidence you collect will make for a stronger argument that you NEED to have this done. 
For now, I just want to say congratulations on 220 POUNDS LOST. That is incredible! No freaking wonder you have a case of major excess skin! You've lost an amount of weight that some lightweight WLS'ers start at! I am so proud of you, you show people like me to keep plugging away and it can be done. So, be sure to document your medical issues with this skin, but don't let that get you too down, your achievements are extraordinary!

xo