Appeals Process and Medical Necessity

Hi -

I started posting over a month ago regarding authorizations that were "lost".  My doctor's office has failed to fix this issue, and I have lost a lot of faith in her staff.  I feel very lied to at this point, and I am no longer sure what to believe.  However, they re-submitted for nearly all procedures, and I now have denial letters (of course).  I did have the TT on June 9.  Since then, I have realized that my back hurts and that the remaining skin that was not taken has fallen onto my hips and into my buttocks.  I don't have a lot of remaining fat.  So, I didn't end up with fat rolls of any kind.

I need some assistance with working the appeals process.  Here are my issues and possible solutions:

Breast reduction / brachioplasty:  The plan was to do this together (which makes total sense).  I am now very disproportionate, and my back hurts constantly.  I am being sent to physical therapy, which will fail as there is only one way to fix this.  However, I need the arms approved as well.  Besides "rashes", what other reasons can be used to demonstrate necessity for the skin under the arms?  In my opinion, it is connected to the breasts and should be removed together to maximize patient outcome.  Although this would be more efficient, I'm sure the insurance company doesn't care about efficiency and best possible outcomes.  

Thighs/buttocks:  As you can imagine, I am really super unhappy about this.  I had been told the thighs were authorized, but now they aren't.  I can't buy pants, and I know that is not a reason for medical necessity.  I do have rashes, which are evident from the photos that were submitted previously. However, I have a lovely denial letter.  Short of having to do another round of meds to get rid of the rashes (meds that make me nauseated and vomit), what can I use as medical necessity?  I am sorta out of ideas on this one.  The only additional reason I can come up with for the thighs is that my knees do hurt.  All of the excess skin on my upper legs sits right at my knees.  

I would appreciate any thoughts or suggestions.  This whole experience has been a nightmare. Unfortunately, I feel even more disfigured after the TT than before surgery.  

Thank you!

I thought I would repost this!

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.

Hi -

I am mentally in a better position now than a month ago to deal with the appeals process.  So, thank you for re-posting.  

I am definitely not going to tell anyone that I may benefit cosmetically in any way.  I think that if they want people to lose weight and keep it off, insurance companies need to consider that we can't get to the end of the journey and be "okay" without some additional intervention.  It is a lot less expensive to pay for me to have a breast reduction or lift than ongoing physical therapy for back pain. You would also think they would want to avoid having to pay for ongoing counseling in order to learn to live with all of this skin.  The cost of psychobabble for years on end has got to far exceed the cost of the surgeries.  

What a pain this all is.  I am bringing in a bunch of records from various providers in order to build my case.  The only upside of my denials is that they read like a road map as to how to get them approved.  The one really ridiculous portion is that I think my doctor's office failed to submit all information to the insurance on time, and that may be the reason for the denial of the breasts and arms.  In fact, the letter reads more like they are missing information as opposed to anything else.  The surgeon's coordinator who works on this just "noticed" this the other day.  The amount of tissue they are looking for is a minimum of 350cc.  The girl actually had the nerve to say..."oh...maybe I should call them in case they are just missing information.  I have all of that info"  

Really?  You think you may have that information?  I wanted to ask her why she didn't fax it to them in August when I told her that they were waiting on the information in order to issue an authorization.  The person I had spoken with at the insurance company had told me they were only waiting for one piece of info - the amount of breast tissue.  He said he didn't need an exact amount - just a ball park figure.  I called her and told her they were waiting on them.  Then when I read the denial, it seemed as if they just didn't bother to give them that information.  So, I have a feeling I am working on stuff that could have been easily taken care of by them.  I mean really?  Is it my job or their job?  I think the first time around it is definitely their job!

Again thank you for the re-post.  It is very helpful

Sincerely,

Denise

Oh! I am glad someone actually brought up the issue about mental health/excess skin! When discussing this with my partner, I was reminded of the benefits of appearance. I know that my insurance company is not worried about how I feel but counseling is not cheap either! Thanks for bringing this up!

Yes...  I am trying to figure out a way to demonstrate that it is less expensive to pay for surgery than for other things on a very long-term basis.  I already see a counselor 2 times a week.  Based on what they currently pay him, that is approximately $8k annually that they are paying him.  If I didn't have the upset of all of this, it is very possible that I could go back to one time per week, as the need for support would be lessened.

I will start physical therapy soon.  I had to postpone due to other things going on in my life.  It will not take long for me to find out how much they are paying for each session.  Additionally, I have read that the weight of my breasts could be straining the muscles in my neck, causing headaches.  I have a very long history of headaches due to the strain of a particular muscle in my neck.  I take meds to help with this, but I land in Urgent Care at least twice a year for additional relief.  I have had more headaches since the TT.  So, how much has the insurance paid for my headaches in the last 4 - 5 years?  Not sure, but I know my medical records will show it. Prior to medication, I was there at least once a month.  So while the medication helps, it is not capable of relieving the headaches all the time.

I have yet to determine how I will put this into an appeals letter, but these are things that are affecting my Activities of Daily Living (ADLs).  

I completely understand. My field before retirement was in Mental Health/Hygiene. Extremely important is the balance of both physical and psychological well being. Keep trying with insurance company. Had video chat with gastric bypass support group and several of them had procedure done with insurance picking up most or all of cost.