2 insurance denials

I haven't been on this forum since having my bypass at 16 in 2012! This site and the ladies helped me a ton and I am now 21 and doing absolutely amazing since losing the weight.

Unfortunately I'm currently in a battle with my insurance company (IBX Keystone Health Plan East through the Philadelphia school district) trying to get approved to have this darn skin removed. My plastic surgeons initial request was denied due to them not feeling it was medically necessary. I appealed and submitted a letter I wrote along with some pictures of just a taste of the irritation caused. I won't post my entire letter here but in short I explained that I was young when I had RNY, when I was out far enough to notice the skin .. and no doctor took the insurance I had at the time so I'd just forgotten about having it removed and tried to live and enjoy my new life. The more I lost the worst it got and unfortunately I was without insurance for about a year so was unable to see a doctor for any of my issues. I explained how disgusting and unhygienic this flap is, how it affects me not only physically but mentally because as a young woman this darn skin is so discouraging. They denied AGAIN this time noting my failed documentation. As I mentioned I submitted personal pictures showing irregularities with my appeal and in my appeal denial reasoning it stated how the pictures didn't show any issues . ????? The rep I was assigned actually told me the pictures taken at my surgeons office were better and she'd use those (mind you they were only of my skin hanging taken in front)

since it began bothering me I've learned how to care and clean myself properly so that it doesn't get out of control but it is still such a pain. It smells like an armpit, and I feel like a baby with a horrible diaper rash at times .

my second level appeal is scheduled for Tuesday and I'm allowed to be on the phone for it . I honestly don't even want to proceed because I feel like they will just tell me to wait , let it get bad, have it documented and get a few attempts at treating it then come back and let us deny you again... the original plastic surgeon I chose refused to do a peer to peer with my insurance company so I thought to seek out another with whom I have an appointment with the day before my hearing . If denied again I will re submit with this new surgeon who is hopefully willing to advocate on my behalf for the medical necessity of this procedure for me . Any advice ir similar happenings and what you did would be appreciated!

Most insurance companies have an appeals board. First find out if your policy specifically excluded post WLS skin removal. If it doesn't see if your are entitled to an in person appeal to make your case.

Having a detailed several and a "letter of necessity" and a surgery date will quicken the appeals process.

That's a shame the surgeon wouldn't go to bat for you. I do understand them not taking personal pictures. Unfortunately you might need proof of actual medical treatment.

Im thinking this past, how did it go?