Help

I am 5 years out and went for an approval for a consult at my PS and have Keystone Health Plan East...I was denied and someone told me to appeal it. I call the PS and the women who does the schedule and put the paper work in to the insurance was no help. She told me write the appeal and good luck. Did this happen to any one else and what do you put in the appeal. Others I spoke to said theit PS office helped them and files the appeal...any input would help. I an a patient from Barix in Langhorne and my PS is Bucks County Plastic Surgery.

I also have KHPE and was denied for arms and tummy.

I appealed once and was still denied. I got frustrated and didn't appeal further.

Good Luck with your appeal.

I don't know very much about the cosmetic/reconstructive insurance approvals/denials stuff, but I do know from experience that almost all insurance companies will deny requests the first time. It saves them tons of money, because most people just give up, or they don't realize that they can appeal.

You really do need to appeal if you meet their qualifications. Speaking of that, do you know what you insurance company requires (conditions like a certain amount of hanging skin or rashes)? If not, you can call them and find out. Then, just follow the steps that you need to follow to make sure that you can meet those requirements (like documentation of those requirements by a doctor, for instance).

Cosmetic surgeons are not the best (and might even be the worst since they don't like dealing with insurance claims) with helping you get insurance approval. You best bet will be to get your regular doctor to document problems that the extra skin is causing you. Have them document it in your notes and/or take photos. You can use the photos that your plastic surgeon took if needed.

If all of this is too overwhelming, you might want to seek out a cosmetic surgeon who WILL help you get approval. There are some out there, but you will need to research and find out who they are.

Hopefully, others who know more about this will post replies. Don't let the insurance company win if you know that you meet their qualifications. Follow the appeals process until they are exhausted, or until you get approval. It takes a while, but it's worth it. Good luck! 

 P.S., I have been denied three different times, for three different surgeries by Blue Cross, and I was able to get approval all three times once I appealed. It CAN be done.

In my experience the appeal process is up to you. You're surgeons office may help w/ providing pictures or the medical diagnosis but that's pretty much it. Years ago someone on here posted her appeal letter which did get her procedures approved. I found that and used it for my own appeal and was successful.

In my case, the surgeons, themselves, called Blue Cross and did a conference call to explain medical need. That got my denial overturned.

In the third case, an "e-friend" that I met on an online forum called Blue Cross and got approval for me right away. I have no clue how she did it, but she was a lawyer, so I guess she knew what she was doing. 

Yes, there are many people who just write their own appeals and get their denials overturned. The insurance companies like to use every single second of their "lawfully allotted time", and will stall with an answer until the last minute. Often they will also deny the second time, and then, approve after the third appeal. Sometimes, people win their appeals by going to appeal meetings after their written appeals have been exhausted. 

Basically, they try to scare you off, but if you meet the requirements that are written in their policy, you will eventually win if you keep fighting. It's a total pain, and a very emotional journey, but it's very gratifying once you win.

Thanks everyone for all the good info...

REPOST from other post! I wanted to be sure you saw this!

Dawnie.........I too have Dr. Lam. My insurance is Highmark Personal Choice Blue Cross/Blue Shield. I have not put in to my insurance yet for coverage but Dr. Lam told me what their requirements are for coverage so I knew what I had to do. When I went to him for a consultation I had terrible rashes that he took pics of under my breasts and under my belly. I also have been taking my own pics. My primary care doc suggested plastics for me when I went to her about my rashes. She sent me to Dr. Lam. I won't be able to put into the insurance company for coverage until I have completed my documentation of 6 months of rashes. It is very sad to me that Dr. Lam's office is not helping you with an appeal. I would call back if I were you and ask to speak to someone there who could tell you the procedure for putting in for an appeal.

Good luck and let us know what happens. By the way I went to Barix too for my RNY. Do you go to the monthly meetings for support??? There are a lot of people who go that have had plastics and might be able to further help you out.

Also another thought....Google....appeal letters foe insurance company to cover TT.....some people have put online their letters that they won an appeal with. Hope this helps. Keep in touch.

Kathy

Thanks Kathy....yes Dr. Lam done the same for me the pic my documntation and all that good stuff...I used to go to the meetings but when they changes into the groups I didn't care for that when Dennis left....Maybe I'll Give it another try.

 I also had dr Lam he has done all my work. I have KHPE  and I was
Also denied, I didn't have time to appeal it cause I had cervical cancer
And wanted it all done together,
 If I m not mistaken u must have lost over 100lbs and ur panni has to hang down a certain
Amount plus the rashes,if ins does cover it will only cover the panni removal
And for the best result u also need the
Muscle tightening which will cost extra. I have Care Credit they
Give u 12 months interest free, that's how I finance my PS
I have found his office staff to be very nice n helpful
G
I also had all of my surgeries done at Barix except my TT cause I needed
A hysterectomy at the same time and that was almost 4 years ago
Goid luck Susan