Question:
How to get insurance to pay bc/bs HMO of Illinois-plastic surgery

I'd like to talk to anyone who has had luck getting blue cross/ blue sheild HMO of Illinois to cover any plastic surgery and how they did it. I'm realizing that I'm being sabotaged by my own doctor because the medical group has to pick up part of the tab when you have an HMO. So it seems they sway me away from EVERYTHING....not just the plastic surgery. I'm going to try and go another route by showing that I have hypothyroidism (which I do) because the AMA's paper that says the reason for having reconstructive could be approved due to disease...and that my weight gain and loss could be due to that (Just some info, I did actually lose the weight recently by diet even though I had the WLS twice back in the 80s). Anyway, I just wanted to talk to others who have delt with that insurance company before or has any other info that might be useful to me. I also do have back problems that are documented and anxiety disorders. thanks in advance for any help you might be able to give.    — Stephanie T. (posted on February 4, 2003)

February 4, 2003
I also hve the same insurance. I found this letter in someones profile. I hope it is helpfull! Abdominoplasty Appeal Letter May 2, 2000 _____________________________ Attention: Appeals Coordinator _____________________________ _____________________________ RE: Notice of Appeal Dear Sirs: Please accept this letter as "Notice of Appeal" In your letter dated April 26, 2000, you declined Consultation with Dr. Miller for Abdominoplasty Surgery. First let me say I was NOT requesting this abdominoplasty for "Cosmetic Reasons". I had Roux en Y Gastric Bypass on December 8, 1999, and to date have lost over 100 pounds. My request was for "Surgical Consult for Abdominoplasty" I require help for reconstruction of a extremely large Panniculus, (apron of fat and tissue) causing me severe back pain and spasms and for medical complications with repeated infections under the Panniculus, which should and is considered a medical necessity. The consult I requested was not for "Cosmetic Reconstruction" as you stated. Definitions: Abdominoplasty is defined as a surgical procedure, which tightens a lax anterior abdominal wall and removes excess abdominal skin. It may be reconstructive or cosmetic. Cosmetic and Reconstructive Surgery: For reference, the following definition of cosmetic and reconstructive surgery was adopted by the American Medical Association, June 1989: Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Abdominoplasty is considered reconstructive when performed to correct or relieve structural defects of the abdominal wall (ICD-9: 701.8/708.9) and/or chronic low back pain (ICD-9: 724.1) due to functional incompetence of the anterior abdominal wall. These conditions may be caused by: 1. Permanent overstretching of the anterior abdominal wall following one or more pregnancies; (ICD-9: 701.8.701.9). 2. Permanent overstretching (with or without diastasis recti (ICD-9: 928.84) of the anterior abdominal wall with a large or long abdominal panniculus (ICD-9: 278.1) following weight loss in the treatment of morbid obesity and resulting in the uncontrollable intertrigo (crease dermatitis, ICD-9: 692.9) and/or difficult ambulation (ICD-9 724.8). 3. Trauma or surgery to the anterior wall of the abdomen resulting in loss of muscle of fascial integrity or pain from scar contracture (ICD-9: 709.2). 4. Abdominal hernia following previous abdominal surgery (ICD-9: 553.201, 553.21). In my request for Surgical Consult my medical necessity relates exactly to Numbers 1-4 all four apply to my condition. Panniculectomy is performed to relieve the massive apron of fat, (which I have attached pictures in the first appeal dated April 12, 2000) is considered purely functional and therefore should be covered by my insurance policy. It is done to relieve uncontrolled intertriginous dermatitis. I have constant rashes and infection causing difficulty in walking and occasionally actual skin necrosis. Page 2 Abdominal dermolipectomy has been performed since the turn of the century. In the United States, H.A. Kelly called attention to this procedure and its positive outcomes (weight reduction, personal comfort, convenience and comfort in dressing, better pose in standing and walking, increased activity and greater ease in hygiene) in his 1910 publication. The anterolateral abdominal wall is largely muscular and aponeurotic with overlying subcutaneous tissue and skin. It consists of two strap muscles in front, (the rectus abdominis and phyraidalis), and
   — sue S.