Appeal?...

I am in need of some information and help regarding an appeal for plastic surgery.   I was wondering if anyone had a sample of an appeal letter. 

We submitted for a panniculectomy and mastopexy based on frequent and recurrent rashes/infections, back pain, embarrasing odor issues, loss of feeling in lower abdominal area.  Insurance came back and said the procedures were purely cosmetic therefore denied based on my policy.  The dr. told me I should appeal stating that obesity is a disease and the cause of the excess skin, which in turn has caused these issues, although I doubt I can argue that with the loss of feeling in the lower abdomen, as that was a result of 2 csections.  I also realized after we submitted that we should of also mentioned the sexual issues the hanging panni has caused, making intercourse uncomfortable to the point of avoidance.

Anyway, my policy states: 

PPK will pay for cosmetic, plastic or reconstructive treatment or surgery relating to the following:
1.  Corrections/repair of congenital anomalies or those resulting from a disease or injury if determined to be Medically Necessary by PPK.

Exclusions:
1. Cosmetic therapies or surgical procedures primarily to restore or alter the appearance, including but not limited to, surgical excision or reformation of any sagging skin on any part of the body such as eyelids, face, neck, abdomen, arms, legs, or buttocks.

I'm not holding my breath that I will get this covered but figured I had to try.  I've been dealing with the rashes for 6 months now...although I did deal with some before the weight loss, they've just gotten worse since then.  They are under the panni, under my breasts, and in my belly button.  With these there are odor issues which I try to keep it clean and cover with powder to help mask.  I've also been in Physical Therapy 3 days a week for about 12 weeks now, due to back pain, which stems from being pulled forward constantly by the excess skin.  It throws off my center of gravity and causes me to be unstable on my feet some days.  I'm on muscles relaxers and have had to have my back adjusted regularly, which I'd never had done before, although I've been on muscle relaxers for fibromyalgia before this. As I said I'm not holding my breath but felt I needed to try.

Thanks so much!

Nina

Your policy language would seem to clearly exclude coverage of post bariatric procedures, rash or no. In addition, looking at your profile pictures, you do not have the bulk that is usually required by most plan language which defines medical necessity for abdominal panniculectomy, etc... I would expect to have to swlf-finance this at the end of the day

I'm prepared to self pay, if necessary...but wanted to exhaust the appeal etc first...

As for the bulk...looks can be deceiving...lol....thank goodness that I've gotten good at tucking and rolling along with the wonders of spanx....my panni unrestrained is pretty thick and hangs to mid thigh....even the plastic surgeon's were suprised at it when they saw it for the first time...making the comment that they wouldn't have guessed from seeing me with my clothes on...then they had to revise how large the cut would be because of how wide and long it is....

Nina

Since it specifically excludes excess skin removal you are probably out of luck on an appeal. 

I'm curious about who told you your pain and instability are caused by the excess skin?  Excess skin by itself weighs surprisingly little, and is nothing compared to the weight you were previously carrying around...

Lora 

My primary care doctor, the physical therapist and the DO who has been working on my back have all told me...it's not only skin, there is still lots of tissue under the skin, I had 2 previous csections before the weight loss surgery and one of the kiddos was really big, so it required a very large extensive cut, which in turn severed muscle, nerves etc and even then left me with a hanging panni, which has just gotten worse.....thus why I literally have no feeling in my lower abdomen now.... 

The 2 plastic surgeon's I've consulted with already said they would not be suprised if there was 15 lbs in my panni area...and I also mentioned to the physical therapist and my primary that that bit of flap was nothing compared to the 100 and some lbs heavier I was....they explained to me that although that is true, you carry yourself differently when heavy...that your center of gravity is different and your body learns to adjust to carry that extra weight more evenly....I can't really remember how I carried anything 100 lbs ago...but as of today, I can tell you I lean forward when I walk...and my posture sucks...I constantly feel pulled forward...some days it just plain hurts like hell to pull my shoulders back and try to stand straighter...I'm doing exercises daily to strengthen the back/neck muscles and make things better...I'll continue to do those...but will self pay for plastics if needed....

My pictures are misleading...in that there is a lot more skin/tissue than you'd think...clothes are amazing...lol.  I always thought I had a medium to large build...as I've lost this weight I've realized that I actually have a smaller build...all that seems to be left is the hanging blobs on my thighs, arms, and abs...and my sagging tube socks...lol...I've learned to roll and tuck very well...and thank goodness for spanx type garments...just as a reference...when my panni is unrestrained and hanging it reaches mid thigh...and is pretty thick....I know it's not that obvious from the pics...but I'm not brave enough yet to post some semi nude ones...lol...both plastic surgeon's talked to me before seeing it for themselves and both were suprised when they actually saw it and had to revise how much they'd have to cut....just goes to show appearances can be deceiving... 

Nina

Thanks for the info.  When I had my panni done, it also hung to almost mid thigh (the mons hug down 3 inches as well, but they wouldn't fix that at the same time!!!), but it was almost exclusively skin... a tiny bit of tissue, but no fat at all.  Even though the surgeon estimated it would be 12 pounds, it was only six.  (The mons was another 2 when I had it done 6 weeks later.)

I caarried so much of my weight in my belly that it's just hard for me to wrap my head around how even a 15 pound panni would cause such problems.  Hope you can get it fixed soon!

Lora

BTW your arms look amazing in your photos!!!

Thanks!

Do you know if your insurance is self funded?  If so the employer calls the shots and the insurance company just administers it.  If that is the case talk to someone in your personnel department.

Red

I honestly have no clue...our Insurance is through my husband's employer, which is a large aircraft company.  I do know there was an exclusion in the policy for weight loss surgery as well, but amazingly Dr. Berntsen submitted for my DS and I was approved within a week...very fast approval, no appeal needed.  They paid 100% of it...and have since paid all follow up care thats been needed.

Nina