Denied
I just got denied for my breasts... I am planning my appeal. My PS submitted the pre auth for mastopexy as I do not have any fat left in my breasts (evident is almost pure white mammo) so could not neccesitate a reduction although I do have documented pain, chiro treatment for over 2 years... The insurance is declining it based on mastopexy being a cosmetic procedure. But the letter specifically states "cosmetic surgery does not include a surgery to correct deformity caused by disease..." I am looking for any information (research etc) to help argue the point that breast lift/ resuspending and skin tightening is reconstructive following massive weight loss.
Let me make myself clear on this... I do not care whether I have to pay for this or not...but I want my insurance to be in agreement that this is not a "cosmetic" procedure.
Let me make myself clear on this... I do not care whether I have to pay for this or not...but I want my insurance to be in agreement that this is not a "cosmetic" procedure.
(deactivated member)
on 3/2/11 1:06 am
on 3/2/11 1:06 am
hmmm i just got a tummy tuck paid for by my insurance... it was pretty easy i did write a in my words letter... very personal heart felt... like so they could see how it was to be me... i think that helped! i never knew u could ask for breasts mine arent to ummm good lol have you got anything covered from them before? if so what? maybe ill try to get mine to cover more! lol
good luck
good luck
(deactivated member)
on 3/2/11 9:12 am
on 3/2/11 9:12 am
I went to a main hospital (mass general) and saw a plastic surgery dr. that specialized in surgerys that people with massive weight loss need. they sent in the letter with pictures saying how medically i needed it. they also told me to write a letter in my own words...saying what it was to live how i did... they approved it in a mmonth.... i have mass health common wealth care.... same people that covered my bypass... i have more info on my youtube channel just look up my name hope this helps! good luck
Aloha-
Part of mine was also covered under insurance ( about $8K).
Aetna covered the panniculectomy portion of my lower body lift after the PS submitted photos demonstrating how low the pannus hung- she said they almost always approve it if the patient has lost over 150 lbs, they document it on their patient website so check your company's manual. But first I went to an in network PS, she submitted and got approval, THEN I had to resubmit when I switched to an out of network PS who did the procedure I wanted ( circumferential bely lipectomy) as the initial PS does not do the CBL in one operation, rather she spaces it over 2-3 months front then back and I wanted one operation for cost, down time, tome off work, etc. Aetna couldn't very well tell me it was not medically necessary with the out of network surgeon after they already approved it with the in network surgeon....but they tried. My PPO coverage merely states I have to pay 20% instead of 10% with an out of network provider, and a $200 deductible- which is small potatoes in view of the total cost ( I had the CBL and breast lift/augmentation all at the same time).
So I recommend you check your company policy first ( recurrent infections, repair of hernia at the same time, pannus hanging below pubis, etc etc) and show that to your PS when you go in for a consult. If the PS is used to operating on massive weight loss patients, they will know how to best submuit it and what angle to take the photos from. I was approved in less than 2 weeks ( even though they never covered my sleeve gastrectomy!).
Good luck- XOLori
Part of mine was also covered under insurance ( about $8K).
Aetna covered the panniculectomy portion of my lower body lift after the PS submitted photos demonstrating how low the pannus hung- she said they almost always approve it if the patient has lost over 150 lbs, they document it on their patient website so check your company's manual. But first I went to an in network PS, she submitted and got approval, THEN I had to resubmit when I switched to an out of network PS who did the procedure I wanted ( circumferential bely lipectomy) as the initial PS does not do the CBL in one operation, rather she spaces it over 2-3 months front then back and I wanted one operation for cost, down time, tome off work, etc. Aetna couldn't very well tell me it was not medically necessary with the out of network surgeon after they already approved it with the in network surgeon....but they tried. My PPO coverage merely states I have to pay 20% instead of 10% with an out of network provider, and a $200 deductible- which is small potatoes in view of the total cost ( I had the CBL and breast lift/augmentation all at the same time).
So I recommend you check your company policy first ( recurrent infections, repair of hernia at the same time, pannus hanging below pubis, etc etc) and show that to your PS when you go in for a consult. If the PS is used to operating on massive weight loss patients, they will know how to best submuit it and what angle to take the photos from. I was approved in less than 2 weeks ( even though they never covered my sleeve gastrectomy!).
Good luck- XOLori
I did have a TT covered with my previous (Tricare) insurance. I had several doctors recommend it following my RNY. I had a large (pubic to sternum) midline incisional hernia that was repaired at the same time so in order to repair it successfully the surgeon stated that the excess skin would have to be removed. They had to repair the upper muscles to allow a place to attach the hernia patch. In total they removed 7 lbs of skin. It hung below my pubic area (at least on the sides because the hernia kept it up in the middle). The docs also stated that there were rashes etc (which there werent as I applied deodorant daily because it would smell).
The thing that gets me is first of all my skin don't do anything anymore...it doesn't bruise, it doesn't swell and it doesnt get rashes... If I was still at 298 lbs 48E and was complaining of back, neck, shoulder pain while sitting on my ass all the time, the insurance would see to reduce my breasts... but now that I am 150, compressed skin fills a whole 36B on a full (PMS) day, Ive embraced a healthy lifestyle, I run 10 miles a day, and complain of back, neck, shoulder, breast, upper chest pain and numbness in fingers... they say it is cosmetic to lift and reattach them since there is not a large amount of tissue to remove. It's not like I can exercise the muscle and tighten them back up... Im not asking to be bigger, I just want to not have to bear the weight and feel compressed all the time. Not to mention my recent dx of fibrocystic which I think is being caused by the compression. I can care less how they look I just want to be comfortable.
The thing that gets me is first of all my skin don't do anything anymore...it doesn't bruise, it doesn't swell and it doesnt get rashes... If I was still at 298 lbs 48E and was complaining of back, neck, shoulder pain while sitting on my ass all the time, the insurance would see to reduce my breasts... but now that I am 150, compressed skin fills a whole 36B on a full (PMS) day, Ive embraced a healthy lifestyle, I run 10 miles a day, and complain of back, neck, shoulder, breast, upper chest pain and numbness in fingers... they say it is cosmetic to lift and reattach them since there is not a large amount of tissue to remove. It's not like I can exercise the muscle and tighten them back up... Im not asking to be bigger, I just want to not have to bear the weight and feel compressed all the time. Not to mention my recent dx of fibrocystic which I think is being caused by the compression. I can care less how they look I just want to be comfortable.
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