Letter For The Insurance Company?
I'm working to try and get Aetna to cover the removal of my pannus (grade 4 according to the PS dr), and I've received a letter back from them requesting documentation and records of skin rashes. The plastic surgeons office suggested that I draft a letter to the insurance company explaining that I've treated these at home, due to embarassment, etc.
Has anyone successfully gotten this covered? Would you mind sharing with me the letter that you used to the insurance company to convince them of the medical need?
Thanks for any help, or advice.
Has anyone successfully gotten this covered? Would you mind sharing with me the letter that you used to the insurance company to convince them of the medical need?
Thanks for any help, or advice.
This is what I sent in:
To Whom It May Concern: I am writing this letter to express to you why I am seeking approval for removal of excess skin and fat from my abdomen and mons. Right now the care of the skin under my “flap," as I refer to it, and around my mons is time consuming, expensive and futile. I am by nature a very clean person. I shower twice per day and have since puberty. I take the time to lift the flap and clean with soap as well as rinse thoroughly. I am incredibly careful to make sure all the skin under the flap is dry when dressing and I am consistent with the application of what seems like endless powders, creams, and ointments. However, after several years of this process I have realized that I will always have this problem unless the flap and mons are removed, and that is why I am seeking the approval for removal. In a given month I may go through 3-4 tubes of antifungal cream - ketoconazole as well as several tubes of clobetasol - at least this is my current regiment - though there have been several others including clotrimazole, diflucan, itraconazole with mupirocin, and probably a few others I cannot recall. These medications add up quickly. It is not uncommon for me to run out of a medication prior to being eligible for a refill and thus find myself paying out of pocket for the required medications not to mention the co pays for these drugs even when I am eligible. I often run out of medications quickly because the area under my skin flap is fairly large and it’s not uncommon for me to experience an infection from hip to hip and down into the skin of my upper thighs around the mons. It’s not uncommon for me to spend $80.00 per month or more on wound/infection care in this area. It seems to me as if one infection clears only to start another in a few days. Additionally, the use of the clobetasol and ketoconazole is exceedingly hard on my skin. It will clear the infection for a few days but during the time the skin is horribly dry and scaly. The skin will then peel off in strips and sometimes cause lesions on the skin. These lesions are painful - to the point that putting on clothing or anything over them causes me significant pain. I once bumped into a counter while one of the lesions was present and the pain was so significant it caused me to cry. The issues with chronic infection have been occurring since 2009. I am at a point where the discomfort, time and money it takes to care for these infections is significantly hindering my quality of life. It’s hard to lead an active lifestyle when I’m constantly worried about whether or not the moisture from my flap is causing an infection. It prohibits me from being able spend significant time outdoors, to work out as long as I would like or at all, and when dealing with painful lesions it causes me to not want my children to sit in my lap or roll around on the floor to play with them. The cost of medications takes away from money I could be spending on my family and in the end this is an ongoing problem I cannot see changing unless I get this surgery. Please give me your fullest consideration as I fully believe that this procedure will have a positive outcome on my quality of life. Sincerely,
My mom who had seen the rashes also wrote a letter describing what she saw, my doctor wrote a letter, i provided pics I had take an home and perscription records.
To Whom It May Concern: I am writing this letter to express to you why I am seeking approval for removal of excess skin and fat from my abdomen and mons. Right now the care of the skin under my “flap," as I refer to it, and around my mons is time consuming, expensive and futile. I am by nature a very clean person. I shower twice per day and have since puberty. I take the time to lift the flap and clean with soap as well as rinse thoroughly. I am incredibly careful to make sure all the skin under the flap is dry when dressing and I am consistent with the application of what seems like endless powders, creams, and ointments. However, after several years of this process I have realized that I will always have this problem unless the flap and mons are removed, and that is why I am seeking the approval for removal. In a given month I may go through 3-4 tubes of antifungal cream - ketoconazole as well as several tubes of clobetasol - at least this is my current regiment - though there have been several others including clotrimazole, diflucan, itraconazole with mupirocin, and probably a few others I cannot recall. These medications add up quickly. It is not uncommon for me to run out of a medication prior to being eligible for a refill and thus find myself paying out of pocket for the required medications not to mention the co pays for these drugs even when I am eligible. I often run out of medications quickly because the area under my skin flap is fairly large and it’s not uncommon for me to experience an infection from hip to hip and down into the skin of my upper thighs around the mons. It’s not uncommon for me to spend $80.00 per month or more on wound/infection care in this area. It seems to me as if one infection clears only to start another in a few days. Additionally, the use of the clobetasol and ketoconazole is exceedingly hard on my skin. It will clear the infection for a few days but during the time the skin is horribly dry and scaly. The skin will then peel off in strips and sometimes cause lesions on the skin. These lesions are painful - to the point that putting on clothing or anything over them causes me significant pain. I once bumped into a counter while one of the lesions was present and the pain was so significant it caused me to cry. The issues with chronic infection have been occurring since 2009. I am at a point where the discomfort, time and money it takes to care for these infections is significantly hindering my quality of life. It’s hard to lead an active lifestyle when I’m constantly worried about whether or not the moisture from my flap is causing an infection. It prohibits me from being able spend significant time outdoors, to work out as long as I would like or at all, and when dealing with painful lesions it causes me to not want my children to sit in my lap or roll around on the floor to play with them. The cost of medications takes away from money I could be spending on my family and in the end this is an ongoing problem I cannot see changing unless I get this surgery. Please give me your fullest consideration as I fully believe that this procedure will have a positive outcome on my quality of life. Sincerely,
My mom who had seen the rashes also wrote a letter describing what she saw, my doctor wrote a letter, i provided pics I had take an home and perscription records.
Kristie
Oh and here are Aetna's guidlines: http://www.aetna.com/cpb/medical/data/200_299/0211.html
I have BCBS - and their guidelines was hangs to the pubis and then the infections. I JUST BARELY meet the to the pubis portion and only because mine is so large that it basically looks like another fat roll and they all roll into one another- lovely right?
If you don't have the medical records to back it up you may want to consider starting to visit your PCP doc for the next three months. Esp if you can find one that is supportive and will help you with getting the surgery.
That way you can take each guideline and show documentation for each one. Then they don't have a legit reason to deny you.
Thats how I approached my request. I found everything I could on the BCBS Panniculectomy approval and then did my best to follow thier guidelines and show documentation. The only one I was worried about was the overall legnth of the pannus - but I was approved so I guess I passed
I have BCBS - and their guidelines was hangs to the pubis and then the infections. I JUST BARELY meet the to the pubis portion and only because mine is so large that it basically looks like another fat roll and they all roll into one another- lovely right?
If you don't have the medical records to back it up you may want to consider starting to visit your PCP doc for the next three months. Esp if you can find one that is supportive and will help you with getting the surgery.
That way you can take each guideline and show documentation for each one. Then they don't have a legit reason to deny you.
Thats how I approached my request. I found everything I could on the BCBS Panniculectomy approval and then did my best to follow thier guidelines and show documentation. The only one I was worried about was the overall legnth of the pannus - but I was approved so I guess I passed
Kristie
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