anthem blue cross?

Has anyone had any luck with getting any plastics approved with blue cross ppo without having rashes? I have 15 pounds of skin, but I don't have rashes, so I'm afraid I'm going to get denied.

thanks

I had Anthem Blue cross out of NY. I didn't have any rashes and after the first denial they did approve me upon appeal. I had a few things going against me for the denial. I was only 14 months Post RNY and they required a min of 18 months among other things. One thing that I believed helped me is since they don't do pre-approvals my surgeons office told me to call to see if there was anything I needed to do. At that time I was told no, do the surgery and then submit. I was not told any of the stipulations for getting it covered or being denied. Not sure if that was the factor in it being approved upon appeal but just glad it worked.

Thanks for responding. What procedure/s did they cover? It sounds too risky for me to have the surgery and then try getting insurance to pay. I can't afford it if denied.

They only covered the Panni removal. From my exprience if they don't do pre-approval tell your surgeon you will do it all as self-pay. Then once it's done submit it for approval and if it's covered you will get some money back from the surgeon. The self-pay rates are much better that if they will submit it to the insurance. Let me tell you I got a bill from the hospital for about 20k for just the panni removal and my bill to the surgeon that covered the LBL, brachio, his fees, anesthesia and OR was 12k. Luckly for me they did pay but if I had know I would have gone self-pay all the way and then hoped to get reinbursed.

 Hey buddy!  Good to "see" you posting.  I have Anthem BC PPO and TODAY I found out my brachioplasty is being covered!  I am so happy.  I found their guidelines for panni online.  Here they are (you know me and my research!)

Medically Necessary:

Panniculectomy is considered medically necessary for the individual who meets the following criteria:

The panniculus hangs below the level of the pubis (which is documented in photographs); AND
The individual has achieved significant weight loss and reached a body mass index (BMI) less than or equal to 30 kg/m2,as well as the following:
the individual has maintained a stable weight for at least six months; AND
if the individual has had bariatric surgery, he/she is at least 18 months post operative; AND
One of the following:
there are recurrent or chronic rashes, infections, cellulitis, or non-healing ulcers, that do not respond to conventional treatment for a period of 3 months; information must be documented in office visit records; OR
there is difficulty with ambulation and interference with the activities of daily living; information must be documented in office visit records.

Soo... go tell your PCP that your skin is "interefering with activities of daily living" ;)
Dr. Bain told me that at the OH conference in Costa Mesa last year, too.

Hey Mary. I don't have rashes or a huge panni. I know it's hard to believe being that I was quite a big fellow.

Does the interfering with daily living just apply to panni, or any plastics. How did you get arms covered?

Here's what I found for brachioplasty and thigh lift.  Thigh lift is never covered, brachioplasty states functional or infection.  I never had infections like where antibiotics were needed.  I had rashes and no proof that they were from yeast or anything.  I did not have great documentation on it.   I have no idea what the surgeon wrote but my PCP wrote a three sentance letter which stated how much weight I lost, from what date, where my loose skin is located and that I get rashes and am bothered by the skin, and that that only appropriate treatment is surgery.  As for functionality, does your excess skin on your arms prevent you from doing anything?

As for breast lift I did not search for anything on it but my surgeons office said it requires congenital defect.  Breast reduction requires removal of one pound frome each breast.  Hope this helps.


A. Brachioplasty:

Brachioplasty is considered medically necessary when done in the presence of significant physical functional impairment and the procedure is reasonably expected to improve that significant physical functional impairment.

Brachioplasty is considered cosmetic and not medically necessary when done in the absence of significant physical functional impairment or when not expected to improve a significant physical functional impairment.

Brachioplasty has been proposed as a treatment for individuals with conditions related to excess skin and subcutaneous fat associated with significant physical functional impairment. Conditions such as persistent infection or maceration resistant to conservative therapy that pose a risk to an individual's health may be indications for brachioplasty.

B. Buttock/Thigh Lift:

Buttock and thigh lifts are considered cosmetic and not medically necessary when done for any reason.