Denied!!

** Hello everyone.. I was just letting you guys know what's up with me trying to get PS. This is a copy of what I posted on the plastic surgery board...

Hi ladies! 
I'm sure yall read this type of post often but it's my turn to whine.
I had wls 1-06. Highest weight was 450. I am now 180. At 1 year post op, I found out I had 2 small hernias. The past 2 months they have been bothering me so I went to a surgeon for the hernias then to a plastic surgeon that was willing to do an adiminoplasty and breast lift at the same time of the hernia repair. I was sooo excited.  They filed it to my insurance company and after waiting over a month, they called me on Monday and told me NO to all 3 procedures! Even the hernia repair!! Their reason for saying no was because all the procedures that I need are a result of gastric bypass surgery and they no longer cover gastric bypass surgery! I am so disappointed! The plastic surgery nurse called me today to apologize and to tell me to appeal.

I got the rejection letter in the mail today and I really want to appeal this!!!

Does anyone have any advise on appealing?? 

Thanks for listening!

Go for it. Keep on their ass. They will get tired and say yeah. Don't take no. Stand up to them. 

Good luck

Amy

Crap! That sucks. They have to listen to appeal, at least on the hermia repair. That's a medical necessity. Talk to your PCP and see if they can write a letter for you. And your surgeon. Even if they don't cover the WLS anymore, the surgeon should have some pull..Especially since they're blaming his work on the hernias...He can clear that little thing up too.

Just so sorry to hear you've been denied..Maybe they just want to weed out the non-serious? I don't know. Keep trying.

Kay,

I'm so sorry, you have worked so hard to get here and it seems so unfair that they cannot even go the extra mile to fini****

I say definately appeal, the grounds for it could be something like :  Even though they don't cover RNY now, they obviously did at the time of your surgery, so denying to fix issues because they no longer approve the procedure has nothing to do with the fact that you have these post op conditions as a result of an APPROVED procedure...

At the very least you should get the hernia repairs, that is completely non-sequetor to the issue of what previous surgery is the underlying cause...Would they say, no to the hernia repair if it was due to a surgery for  say gallbladder ( example )...(I'm going to use me as an example but you can relate it any way you want )...I too needed a hernia repair, it was due to the incision line crossing my open RNY and a gallblader removal incision, when I had my gallbladder done in the early 90's it was still a full abdominal cut procedure for many doctors so I was cut from left to right, they don't do gallbladder in this way now ( so you could postulize that the insurance no longer does this procedure ) but I still got a hernia because of the hernia repair cut crossing my RNY cut...

If you can get the hernia thru then maybe you can self pay the additional expense of panni removal ( my surgeons additional cost for the panni was $1000 since all the operating room fees and anestesia was already covered by the primary surgery )...

Good Luck...My prayers are with you...Keep us posted...Alesia

That sucks! And is kind of BS too! Appeal for sure. It certainly can't hurt. I would TOTALLY recommend that if you can at least get the hernia repair covered that you pay out of pocket the skin removal for sure (even if it isn't an actual tummy tuck). It will be much much much less since other expenses will be covered. I wish I would have done that when I had my hysterectomy!!!! Good luck!

Kay,
I was denied as well for plastics by two insurance companies. I was still appealing when my company switched insurance companys this year. I have not started an appeal yet. The first insurance company approved my hernia repai but I did not get it done as I was appealing and I want to combine surgeries. I am afraid this new insurance company will try to deny my hernia repair as well. I had a CT scan which states per the radiologist he cannot tell if the hernia is from my GBS surgery or was just there. I see the surgeon for hernia consult on July 6th. I went to the UW school of medicine for my plastics consult, a resident does the surgery with a chief surgeon in the room. TT and LBL will be $6620. I just got a bonus that will just about cover it. I am so hoping not to have to fight about the hernia repair with the insurance company.
Where is your hernia? Mine is by the belly button so that is why the doc said he could not say for sure what caused the hernia. I would definately appeal, especially the hernia issue.
Good Luck
Mary

Hi Mommy LOL
I have 2 hernias and both of them are above the belly button and incisional from having open gastric bypass. I am going to appeal and hope and pray that it goes through. If it doesn't I'm going to try to either switch insurance companies or go back to Vocational Rehab to help me pay.
I work at the medical university of SC and have heard of residents doing the plastic surgery for a very good price. I'll have to look into it.

GOOD LUCK with your surgeries! 

I am sorry for your problem.  I would keep appealing.  Also can you go in for an appointment every time you get a rash?  Every time something hurts?  Would they get tired of appointments etc. and cover it?  daisy