Denial of Reconstructive Surgery...Medical Mutual

I have Medical Mutual PPO, and I had gastric bypass surgery 6/1/03...since then ive been having upper/lower/neck and shoulder pain, rashes, cuts from over laps of skin over the bra...and was just told that i have a umbilical hernia. I submitted my doctors notes, letter from plastic surgeon and obgyn notes, and im still getting denied, stating the services are considered cosmetic. I am at a loss as what to do next! I really do need to have this excess skin removed, im 27 yrs old and im tired of feeling like im older than what i am, cause by body is carrying all of this excess skin! I would like to know, who is the PS you used, should i go to another doctors office, and have them submit the appeal for me and im even considering saving up for the procedures. I'm in desperate need of an tummy tuck and breast reduction...the others i can pay on my own...cause they may be cosmetic. Any insight would be helpful.. Have a good day..*_*.. Nicky 353-196

Hello, I am in the process of appealing my insurance company's decision for the same reason. To my knowledge it is your responsibilty to fight the insurance company. I submitted my own info(letter and personal photos) and got support letters from my other doctors to submit with my appeal and I am waiting to hear something from them. A lot of times the insurance company doesn't listen to the plastic surgeon because they are the ones doing the procedure and getting paid for doing it. I have also heard that most insurances will deny you first and if you fight and prove that it is medically necessary they willl approve it. I have also heard that no matter how much you prove it to be medically necessary they just won't approve it because they save money and they are gona say it's cosmetic regardless. For me, I am gona fight to the end. I can appeal 2 times so my first appeal is still in review. I am hoping the outcome will be positive but if they deny me again I am prepared to fight one last time.

Breast reduction is not cosmetic if you have enough tissue. I don't know how much is the amount that they say is enough. I had 5 pounds removed. Wow was it a relief. This was not associated with weight loss... though. I was just too big!!!

That was my understanding too. A breast reduction is covered by many insurers as long as there is at least one pound, or 454 grams, of tissue to remove from each breast. Then it is considered reconstructive instead of cosmetic. For Tricare Prime, the lift is covered as long as there is sufficient ptosis (measurement between collarbone and nipple) to justify it. The neat thing about the reduction is that it is usually accompanied by a lift anyway! Good luck! You want to fight for your insurance company to pay for these things in case you develop complications. Then your insurance company has to pay for those as well.

Hi Nicole, I was reading through the posts and saw you have TriCare Prime and have had some plastic surgery. Can you tell me what you had to do to get them to pay for it? My doctor is right now recommending a breast life and tummy tuck - what surgery/surgeries did you have done and did TriCare give you any problem with them? So far they have been wonderful to deal with but I want to be prepared if they say no or want other info. I have been doing PT for back pain and seeing a back specialist also. Any help you give would be so appreciated! Thanks, Cindy

Hi Cindy! I had a giant abdominal hernia repair with extended abdominplasty on March 18th with the most amazing results! My PS and general surgeon submitted to Tricare for a breast reduction and lift, circumferential thigh lipo with medial and lateral lifts, as well as the abdominal work. I was approved by Tricare for all of it pretty quickly and the approval for legs and breasts is good as long as I have it done by October 1st. For me the abdominoplasty instead of panniculectomy was due to that hernia. I had it repaired in June 2004 without abdominoplasty and it popped out again in October. My PS and general surgeon submitted that I need the muscle work of a total abdominoplasty as a support structure to help keep that hernia in. This keeps poor Tricare from having to foot the bill for more hernia repairs on that hernia in the future. My breasts qualified for the reduction and lift based on Tricare's own standards of ptosis (sag). The measured my breasts and I had at least a pound of breast tissue to be removed form each one, which qualified for the reduction portion. On my thighs, as I was a pear pre wls, I have a tremendous amount of hanging, drooping skin both inside and outside my thighs. I have to spread my legs unreasonably far to get the skin to separate enough to see light between my legs. As there is a lot of traction on the skin when I move, it was considered obstructive to normal function as even support hose couldn't compress it enough to allow trauma free movement. I also found lots of lipomas and other blobs of encapsulated hard fat stores that needed to be removed and Tricare would be happy to have it all odne at once and save the money from paying for many multiple procedures in the future. If your PS can prove with supportive documentation and photos that your skin impairs normal function, Tricare is great about approving it. While this made me feel like a really sad pre plastics case, it has also made me realize the huge asset having a great team of talented surgeons can be towards getting insurance approval. I didn't have to submit a letter and Tricare didn't even ask to see my terrible pictures to support the submission! I'm assuming they must have reviewed my file right before lunch, deciding to preserve their appetities for hurriedly approving my procedures so they could be rid of me! LOL Good luck on your journey! I am so very looking forward to the rest of my surgery! I'm even tempted to treat myself to a mini brachioplasty after the major work is done.

Hi Nicky I definately fall into the category of denied by insurance regardless of medical necessity as described so well by Cassandra! My recommendation would be to appeal the denial but consider switching insurance companies if needed as well as self paying if this is a possibility - not that one should have to self pay for medically necessary RECONSTRUCTIVE surgeries, but if you keep getting denied, eventually you will have to figure a way to deal with the problem. Sure hope this helps and know you aren't alone... Hugs, Caroline Lap RNY 5/2/03 and -223 lbs LBL & Mastopexy 1/17/05 Extended Brachioplasty & Mammaplasty 2/12/05 Circumferential Thigh Lift & Buttock Lift 4/05 OH Profile: http://tinyurl.com/bkld Photos: http://picturetrail.com/carolineam