@#&%?& Curse fit...Crap News....Denied.

Hi everyone, Happy Friday! 

Except a little sad & worried. So here goes I'll share. After all this time spent, I received a call today from the nurse case manager @ My insurance company Empire BC BS NY/United Health care and was notified I have been denied for my tummy tuck/ hernia repair.

I was going to use Mark Schwartz NYC and I really like him. He was going to do the extended tummy tuck and Pomp was going to do the hernia repairs. 

I didn't anticipate a problem as my ins is norm pretty good, great actually. Even my DS approval was super quick but then again Pomp's office was handling it and was on it.  

I can appeal this but, don't hold out much hope considering we had pictures, documentation and other doctors recommendations, dermatologist, chiropractor so what else can you do? I read and read and followed the policy requirements? did what the Dr's said. It didn't work.

Plus I should mention the Ins lady @ the plastics office is not impressing me. I may ask for copies of exactly what was submitted? and start there.

But, since my guts are spilling out of the front of me I wish they would take it a little more seriously. My option now is just to fix the hernia but they say when the muscles aren't repaired you could require future surgeries. Why not tighten the muscles and lessen the chance of recurrence or help someone before they have a bowel obstruction which is much more expensive. This is really outrageous and more ridiculous.
 
Apparently my fat doesn't hang low enough past my pubic bone. Out of everything that is what they say? I wanted to crack up laughing who gives a **** about that when you have to poke your own intestines back in through a whole in your stomach and have a huge alien sticking out of your belly. Not to mention it looks like it hangs pretty damn low to me, plus rash pics... was my Ins examiner wearing their glasses....I dunno...lol.

I just wanted to get away with only one all in one surgery on my stomach area and be done with it & it didn't fly. Thank goodness I didn't ask for help with my tube sock boobs or flabby arms & thighs that would have been a laugh.

I have about 80 grand in student loans on top of my mortgage and other responsibilities like many of us with a family to support or I would just borrow it and save myself the aggravation of this whole experience & pay it myself to complete my journey. You just work so hard to get here and this is so crushing.

I have just known and read about so many people who were successful in getting insurance approval for panniculectomy/abdominoplasty I was too hopeful I guess. I must have missed something.

Thanks for the rant. This too shall pass :) and I will figure this out somehow! most likely with some help from my oh friends so...

Any tips or pearls of wisdom? similar experiences? can anyone relate? TY

Best,
L  

Aloha LP-

I know it's taxing on your sanity, but I'd appeal at least once if not twice. I'm stunned if you have a hernia that they are not taking care of this as part of THAT! WTH are they thinking- that they'd rather cover you for an entrapped strangulated bowel than take care of everything all at once? Makes no sense,

For brevity's sake, PS= Plastic Surgeon
INP=  In-Network Provider
ONP=  Out-of -Network Provider

Not sure if this has any impact on your situation, but here's what I did. I consulted with 3 PSs:  one was an INP and 2 were ONPs. The ONP PSs did not want to mess with the insurance company- said the panniculectomy was rarely covered, wouldn't cover muscle tightening, had to start and stop timers on anesthetist-surgical assistant-operating room, blah blah blah. But my insurance company lists its criteria  for panniculectomies on their member website- pannus hanging down below your pubis, recurrent infections, loss of over 150 lbs, as part of a hernia repair, etc so I knew sometimes it was covered.

The INP I consulted with submitted my history and photos, and I was approved within 2 weeks. I then had resubmit to change the pre approval code over to the ONP that I chose to do the surgery (  he does a circumferential belt lipectomy front and back all at once, the other 2 PSs did not). Get this - at first my ins company denied me- but since they had already considered it medically necessary under an INP, they couldn't really tell me it was no longer medically necessary simply because I was electing to have the procedure done with a different surgeon, could they? It cost me slightly more- I had to cover a $200 deductible, and associated costs would be covered at 80% instead of 90%  ONP vs INP, but that amount was not overwhelming considering the entire cost of all my procedures .

 So I'd  consider resubmitting with a different PS ( choose an INP who has had success in getting the procedure covered before). Once approved, you then need to jump through some hoops to switch it over to an ONP, but it's contradictory for them to deny you with an ONP PS if they've already considered it medically necessary with an INP.

Another suggestion before you call it quits- check on the insurance board, or look up Diana Cox on the DS board - she is a wealth of information about all things legal, surgical, DSical- here is her profile:

http://www.obesityhelp.com/member/dianacox/

Appeal! XOXOLori

Hi Lori,

Thank you! I really appreciate your time and this is great information you provided. Also I appreciate u validating my feelings on how it makes no sense because that is what is bothering me most.

It is so taxing emotionally your right. But, I will be persistent. I am just whining now and going through the stages since I just found out :) that's why i came here to share I figure why suffer in silence when so many people here have been and are going through this same thing or similar.

I also really feel stuck between a rock & a hard place because like I mentioned Dr. Pomp referred me to Schwartz because he is doing the hernia and Schwartz the ext tummy tuck. I guess Schwartz has privileges @ Dr. Pomp's hospital (Weill Cornell). Both are ONP for me.

So my original plan when I set out to look into this 6 months ago~ was to meet with different plastic surgeons interview etc....but, after learning the GS fixes the hernias and a PS does the muscles- I figured it is very difficult to coordinate Dr's so I really should stick with these 2 that have worked together before with WL patients and were willing & able to do so.

Their are actually INP a lot closer to me that I ruled out due to not being able to coordinate them with Pomp in the city & obviously I liked Schwartz when I met him although the office help concerned me off the bat.

So this got me wondering if I should have just found a general surgeon who is also a PS to just fix both the hernia and complete the TT However, I really feel better w/ Pomp knowing he knows my DS configuration if anything arises. Plus these dually qualified Dr.'s are harder to find than I thought.

That said I never even thought of what you mentioned above and it makes a lot of sense and I will certainly try it. This seems like a really reasonable and effective solution so bless you for sharing. The plastic surgeons office has left it on me anyway to contact the appeals dept and find out what I need to do and what they need to do and then call them back~ so its on me.
 
Even the fact that they are not going to handle it for me confuses me because I have a friend who's local PS office handled all of it and they spoke to no one? She was denied on the first try and then they appealed for her and won & we have the same ins. But, she was also not sent to dermatologist and chiropractors. Which is fine and I didn't fuss over jumping through some hoops I figured best to follow the instructions to a T so I played along.

But, For example, I was driving an hr away three times a week to a chiropractor the PS ins lady recommended because he writes good letters & they have a rapport with him? I had to pay him cash $40.00 visit plus whatever the ins gave for ONP as he is ONP too and worse each time he pushed on my back my hernia hurt bad and has become bigger and now I have 2 hernias (so I have stopped going) and it didn't seem to help this cause any just FYI for anyone reading...plus any logical person has to wonder why am I going to a chiropractor to put on a show & appease the ins company when it is worsening the real problem that really does exist? what is wrong with this picture?

Just more time keeps passing as my hernia worsens and my main concern is my health not just vanity (yeah would luv a flat tummy who wouldn't but would rather have my guts secured where they belong if u know what I mean) so my main concern is I don't need a bowel strangulation while they keep piddling around with this crap. It just feels wrong to fix the hernia and not address the muscles @ the same x.

So bottom line is maybe a different office in the mix would really help push this along. Like you said all these offices have different quirks in dealing with the insurances & my office reminds me of the type that prefers cash. Typical Manhattan Dr.'s office. I pd a nice consult fee too already so I am not so concerned with adding some money for deductibles & such considering the over all costs involved. Plus I don't expect to get off Scott free- I'm flexible but I am only good for a reasonable portion not the full $11,500.00 and certainly not the hernia cost I do feel that is the insurances responsibility.

Oh and before I forget... yes I thought of Diana too she is so wonderful but, I figured not bother her cause its PS not really my DS. However, you are right either way she is so great with the legalities & Insurance~ Larra too!

xoxoxo to u Lori...THANK YOU! I will keep you posted.

Best,
Laurie

sorry to hear all this I have Cigna and they have always been super -- fast WLS approval, etc...yet denied twice for skin issues...so when it came time, 401K for my boobs and my stepdad loaned me the money for my LBL and I will pay him back when my house decides to sell.

Thanks. I have already started saving in case but, I am years away. So whats meant to be will be.

Sounds like you worked it out nice though so there is always a way. Good luck with selling your house!

Please please appeal, appeal, appeal....
I got 2 appeal denials and only was approved after external appeal.
Michelle is not big help, I know.
You have to do it.
Dr Schwartz is amazing, I loved him so much.
please let me know if I can help.
Alla

Hi Alla,

So glad to hear from you! I am always glad to hear Dr. Schwartz is worth it cause she really puts me off with the attitude.

I will keep at it but, it is just trying on your nerves ya know? I just find myself like today trying to work all day and deal with the insurances and then Michelle on top of it which u said it :) not only is she not a big help she is totally counter-productive.

So I also talked to Robin and went over the submission & why and how we are to fix it. They didn't like it but, too bad the ins lady said if BCBS approves UH will have to also and vice versa. So I say we do exactly what she said.

Plus the insurance said they were willing to reconsider without an appeal? So even though that's no guarantee I thought it was a positive step? So I got on everybody today to try and fix this mess and hope it works because I need them to do their part and I am doing mine. if no luck then yes we appeal, appeal, appeal!!!! Do what it takes. Yikes...

But, I got a lot of great advice so i am feeling better about about my options. Thanks all!

How are you feeling? Healing well I hope?

TY,
Laurie