State hearing??

 So, the other day I saw someone post on a few pages that he took his insurance to court and actually won. Well I guess it's my turn! There is no money to put back so if insurance won't pay it's a no-go. My PS applied for the fleur-de-lis abdominoplasty, arguing that a simple panniculectomy will cause issues with healing ( he can make it work if that's all they end up covering though, he said its worth a shot)
 So, of course insurance said no. I figured after the second "no" we would apply for a panniculectomy but PS really thinks that if I take it to court I'll get it because of my extenuating cir****tances. He says they have won in court against blue cross before. SO... We are giving it a shot! As soon as I get a date that is!


Has anyone been to a " state hearing" ..? I don't know what it's like. Is it a big courtroom or just a conference room? Is it less formal than normal? Kinda happy that I get to "explain" to someone in person instead of arguing with a piece of paper!

okay, so, I may not be the best person to answer that question, since I've never been down that road, but I am in law school, so I can decipher some of the legal writing mess sometimes. as is standard for all my fellow students as I, major disclaimer: I am not a practicing attorney, haven't been licensed by the bar, and am not able to give legal advice. But I will try to give you general info if no one else knows the answer to your question. Do you have any pieces of paper with the current rules/statutes/ways that you're challenging your insurance? who filed the action?

 No worries =) I'm thankful for any "non-advice" I can get haha. I went to medical school to be a medical assistant but had to drop out because of all my post-RNY issues so I do understand as one of our most practiced statements was "I cannot legally give you medical advice nor should you take what I'm about to say as replacement for going to see a licenced medical professional" blah blah blah...yeah yeah lol.

Anywhoo - the papers were filed by my plastics doc but *I* am the one who needs to go to the hearing. On one part of their "rulebook" it states that abdominoplasty isnt covered at all (unless medically neccessary) - another part states it is NEVER medically neccessary (except in extreme and rare cases). I'll see if I can find it again and pop it up here. My letter to the insurance company basically points out all the requirements for a panniculectomy *which they refused as well as the full on tummy tuck) the only thing I'm missing is rashes being documented but those are on a line with an "or" in between. It's either rashes "or" over 100 lbs weight loss...well 265lbs kinda goes over 100 so ..yeah. I'm asking insurance to reconsider the abdominoplasty but if they cannot approve it to downgrade to a panniculectomy (which I meet and exceed all their requirements and pointed it out in my letter).

gotcha. The answer to who you'll be speaking in front of, and whether its formal or informal depends on who has the authority to review their decision. usually, health insurance companies have an internal appeals process, where you can have them review their own decision and try to convince them that you meet the criteria. Also, many states guarentee certain rights of patients that insurance companies must abide by. The terminology "state hearing" makes me think it may be that, though I have never specifically encountered it. The trick either way is to know what is written about coverage, and how you fit into that.

Usually, regardless of whether the appeal is internal or external, they are required by law to tell you how to appeal a denial in the actual denial, and how long you have to do that. it's time sensitive. And on there they should list the documents that govern the claim- be it a state statute, the language of their written policy, etc.

In your situation, I'd talk to your doctor- ask him what the process looks like, what resources he would recommend, and how you can prepare. I would also try to get any documentation possible so I knew what the subject material was and how to best argue that I fulfilled it.

Hearings usually are a gathering of people reviewing information- they can be more formal and look just like a trial, or even some where you aren't invited at all, and they just look at what you've previously submitted and independently decide whether the insurance company erred by denying you.

If you find a specific law or state code, I can look at it and tell you what I think about it. sorry that was super general, law stuff varies a lot by jurisdiction

 The following is what my surgeon and I are going by. We know it's a long shot of actually getting the full abdominoplasty covered being as their book says it's NOT a covered benefit. However, a part of their book states otherwise:

This is taken directly from the Anthem Blue Cross Medi-Cal Patient handbook...

"Reconstructive surgery" is done when there is a problem with a part of your body . This problem could be caused by a birth defect, DISEASE or injury . IT IS MEDICALLY NECESSARY TO MAKE THAT PART LOOK OR WORK BETTER.

Medically necessary or “medical necessity"
means reasonable and NECESSARY types of service to protect life; KEEP THE PATIENT FROM GETTING SERIOUSLY ILL OR DISABLED; OR REDUCE SEVERE PAIN through the diagnosis OR TREATMENT ofdisease, illness or injury.


The bold parts are just for here for emphasis lol.  My primary, my plastic surgeon and my gastric surgeon all agree that we could possibly win with that alone being as I meet all the other requirements for the panniculectomy. Honestly, the plastic surgeon already said he can do a sufficient job with just the covered panniculectomy but would like to see me completely happy and go for a full abdominoplasty - that's why we're trying so hard to get it. I NEED an actual belt lipectomy but thats like a .002 % chance and not really worth fighting for lol.

Thanks for your help by the way!  ^_^ very much appreciated.  We've applied, been denied...appealed the denial..that was denied..we appealed that...denied and now we're taking it to court which is just exercising my "right to a state hearing". It's blue cross medi-cal which is poor folks insurance by the state (california)

you and your doctor have the right gist using their own language to make your case. I'm not at all familliar with california law since I'm over in Florida, so I can't tell you much about your hearing, but if your doctor has done it before and is willing to assist you through the process, then you're in a better position than many. my guess is that the hearing will be with one or more judge/someone acting in a similar role/someone looking out for the state's interests, someone *****presents the insurance company, and you and your doctor (and your or his lawyer, if y'all had one).

taking it to court can be helpful in close cases because often the insurance companies dont have the incentive to really fight it- the amount of money they'd spend on defending it is often makes it worthwhile for them to just acquiese.

good luck!

 Thanks! I personally think they leave those loopholes for a reason. There are certain cases that they need to be able to put forth payment for a patient - I think this is one of those cases. Heck, the plastic surgeon estimates about 20-30 lbs of excess skin and 10-15 of it is upper abdomen alone. The upper is what is KILLING my spine and preventing me from working or even sitting up longer than 2 hours for homework! I don't care about a muffin top, scarring or looking perfect, I just want the extra weight off my back, unfortunately a plastic surgeon is the only one FOR this job and I think as soon as they see a cosmetic doc submit something they just start yelling "no".