"Lost" Authorizations - How do I navigate the insurance problems?
Hi -
My PS' office "lost" my authorizations for thighs, arms, and breasts. I know...everyone says they are in the computer for the insurance company, but they aren't. They re-submitted for the breast surgery, as the health plan had authorized it under the wrong code. It was denied. The insurance company seems to have lumped the brachioplasty in with this denial. I don't know why, but they did.
The doctor's office has a legal team working to get the authorizations back, but I don't have much hope. Has anyone had to write an appeal to get a denied surgery authorized? If you have written a successful appeal, do you have any advice? I'm literally exhausted from this process. This has been going on for nearly 10 months.
I did have an abdominoplasty in June. The doctor states that the health plan attached all the authorizations to the first date of service and that is why they are now "lost". It is extremely important that the thighs get lifted. I can no longer buy pants. I keep trying things on, and nothing looks right.
Thank you for any thoughts you may have on the subject.
-Denise
Denise,
My guess (and I could be wrong) is that if the insurance company does not have the approval in there computers .........it may have never been approved, otherwise, it would be no problem to get the copy of the approval. When docs summit billing it is paid base on what is approved on the data base.
I was refused arm, thigh lift and lower body lift from get go because these PS is not usually the norm under most insurance. Breast reduction (not breast lift) is usually cover by most insurance if 500cc of tissue or more is removed. There has to be documentation on this.
1st......when initial pre approval was sent in to insurance (doc office did it) pictures where sent of all body parts. Everything was denied except breast reductions. At this point, it was up to me to appeal the decision with my insurance co. 1st appeal............I included documentation from my primary doc. re: rashes and yeast infection and documentation from my neurosurgeon re: extra skin causing problems with my lower back. I sent in visit notes from each doc plus letters from each doc. ( I appeal the decision really knowing that it would be denied.) It was denied based on the fact that yeast infection cleared up with meds. and no evidence that my back would improve with panni removal.
I appealed this decision (final appealed with final person (in my case with Human Resource at my work because all medical is paid by my employer and the insurance co. just oversees it.) Most likely, the third appeal would be done by the your state health insurance commissioner which should be listed on your second denial letter.
I summited the same evidence re: PS to the Human Resource guy that I did to the insurance and added about what I have to do to maintain my current weight and why skin removal was important. My argument was that to keep my weight off and diabetes in check I needed to exercise. Due to back problems, I could use a cumberance bike or swim. When I have rashes under the panni area or in they area...........I could not swim or bike due to making rashes worse which has a direct impact to my success with keeping my diabetes in check. The final decision.........lbl with tightening, arm and thigh lift, and breast reduction with lift all approved. I just had these procedures done in the last 8 weeks.
I have to be honest and say that I am shocked that all was approved. So is my PS. My hopes was to get panni removal and breast reduction. It took me 20 months to get this approved.
Do not tell the insurance company that you can't fit into pants and that they do not look good on you. That would be an automatic denial because that is cosmetic which does not impede on health.
Also, check to see what your insurance says about plastic surgery and what it covers. Mine read no PS covered even after WLS. .........don't let that stop you..........you got nothing to lose in try (except for skin).
Good luck.
