Rashes and Insurance Help!

There's a long story leading up to this aside from losing 135 lbs but after having to have a massive chest surgery, my oncologist ordered a breast reduction (lift). I went to see the plastic surgeon and he said that he was confident that he could get a tummy tuck covered by my insurance as well because I have chronic rashes. I had them even before weight loss. It was all denied by my insurance. The plastic surgeon had to appeal my case but they finally approved the breast reduction (yay!) and that is scheduled for about 8 weeks out but they denied the tummy tuck for lack of medical necessity. It turns out that my dermatologist who was treating me for bloody, nasty infections in the rash area hadn't sent the documentation to the plastic surgeon so it's no wonder that they denied it. The surgeon is only able to appeal one time. He told me that if I appeal it with the proper documentation and photos of the rash, etc., I have a good chance of getting it approved.

My question is, have any of you had to do this? I want to be armed with as much information as possible before I do it. This is REALLY important to me.

Thanks in advance!

congratulations on your breast reduction approval!! (breast reduction and breast lift are very different procedures, I am sure your plastic surgeon got a breast reduction approved which is rather simple to get approved for a plastic surgeon since it is simply based on volume reduction)

there are a few inconsistencies with your post....

whoever appeals an adverse decision, (in your case you state the plastic surgeon did) is responsible for making sure all pictures, letters of medical necessity, operative reports, medications, chart notes, peer reviewed journals etc are attached to the appeal.

what does your subscriber agreement state? what is their definition of medical necessity in the subscriber agreement? what is the appeals process? what did the letter of medical necessity you got from your dermatologist state? what did the letter of medical necessity from your pcp state?

whoever told you your surgeon is only able to appeal one time, doesn't understand the appeals process, or just plain lied to you, that statement is false. your appeal(s) can be appealed by you or anyone else you appoint, and not just the first one. I would never have a plastic surgeon appeal in my behalf, they are not equipped with the amount of time and research that is necessary to appeal this.

you state that your dermatologist didn't send in the information? it is your responsibility to make sure this goes (the person who appeals, if you gave that right to someone else, your plastic surgeon, it is their responsibility...see why you never have a ps appeal on your behalf) be very careful who you give the authority to appeal. know your subscriber agreement, read it from start to finish, know what medical necessity is, know the exclusions, and adhere to your time tables around when you can appeal. keep reading and learning. I wish you well in your journey to get healthy

I asked my insurance provider what information they required for approval for a Panniculectomy, removal of only the overhanging abdominal skin. I have been documenting with pictures monthly for the past year, and my PCP and surgeon also make note of the rashes at each visit and what medication/powder/cream prescribed.

Gather all the information you can from all your doctors and send it to your provider yourself.

Good luck!!

Thanks for your responses.

My breast reduction had to be postponed because now I need a hysterectomy (complete) and I tripped back in August and tore the cartilage in both knees. They're not heeling, in fact, I'm now on crutches and I need surgery on both knees (one at a time).

I have almost all of my information gathered to appeal. The plastic surgeon will not appeal a second time but he and his RN are confident that I have enough documentation to prove that it is medically necessary.

I just want to feel normal again.

Thanks for your responses. It's been a while since I've been on. I've had a complete (full-open) hysterectomy (unplanned), a breast reduction and a revision since my last post.

I did receive my approval for my belly lift and surgery is scheduled. I was able to get insurance to cover it so I am SO grateful. I cannot wait to get rid of these rolls of skin!