Insurance Denial

I had GBS 8 years and 3 children ago and am now getting PS. So excited and nervous. Surgery is scheduled for a week from today! I never went to my pcp for any rashes (which didn't happen often) but have chronic lower back pain due to the excess skin. I got 2 great letters from my pcp and chiropractor to send to my insurance company (BCBS of Illinois) and they have denied it as medically necessary. The ps doctors office sent in an appeal and I was wondering how often insurances change their mind. I want to be hopeful but have no idea what is the norm. Do they automatically deny all of them or just mine? Frustrated! Also, when they denied it, shouldn't I have also gotten a copy of that letter?

I am in the process of getting PS also, I have BCBS of PA and I called them.  They said they do not cover cosmetic surgery but if you have rashes or problems from the extra skin they consider it.  They told me to get pictures and all the paper work from my doctor about rashes and pain from the extra skin and have them send everything along with his recommendations and they will deny or accept it and if it's denied she said to appeal it and then they have a meeting and collect everything they have gotten and hopefully it works and they accept it.  They did tell me though they do not cover a tummy tuck, but they will a panni if it's approved. 

Good Luck

I am in the same boat guys.  All my stuff was supposed to be submitted yesterday.  I hope they don't take the whole 30-days to give me an answer.  I had letter of necessicty with scripts from PCP, I saw one PS so I have documentation and pics of rash and ventral hernia from him to send with second opinion of cheif PS who took lots more pictures (the rash was worse, spread more and was bleeding and seeping, plus the ventral hernia was rearing itself well that day.  All this has gone to BCBS of Fl.

First and Second PS says ventral hernia has to be reparied and TT will be done cuz they have to cut me there anyway so I don't know how they are going to get that thru.  I did tell them insurance won't cover TT but will consider panniculectomy if medically necessary.  PCP and both PS say it is definately medically necessary so now I wait. 

I wish you both luck also.

Carla

You're right, they wont cover a TT, but the PS deducts the cost of the panni from the cost of a full tt and I would be responsible for the remainder. I keep praying that they will decide in my favor. Good luck with both of yours as well!

Oh I so feel your pain! I got my denial letter from Horizon today...figured they would deny the TT, but had all the documentation that they wanted for the boobs..on Monday will call to start the appeal process....it is very depressing!

It all depends on what your insurance policy covers and what criteria must be met in order to get it covered.  If the policy states rashes must be present and you have none documented, then I don't think you'll have much luck with an appeal.

You need to get a copy of the clinical policy bulletin.....that will outline exactly what is covered and under what conditions.  Then you can work on meeting those conditions, though it may mean postponing your plastics.....