Question:
How do you deal with an insurance denial for reconstructive surgery? I found an

awesome plastic surgeon (Dr LoMonaco) and had a complete consultation. They submitted my pictures and all to my insurance (United Heathcare)in order for me to have a panniculectomy. I just got the letter with the denial. I am crushed and surprised. Yall, my stomache lays over my thighs, causes my thighs to go numb, covers my genital area, and looks like hell. I have to lift my apron to go to the restroom or have sex. I sure need some help with how to deal with the disappointment and upset. I still have weight to lose but it is bad now. Very sad in TX    — Ann B. (posted on May 25, 2004)

May 24, 2004
i have found that most times the information that the doctor sends in is often not enough or not worded the way the insurance company wants. get a copy of your insurance handbook. sometimes you can get it online. find the section that deals with reconstruction and take it to your doctor. each insurer has different requirements and certian points that must be met. if you meet the requirements they can't deny you. since you need reconstruction for medical reasons and not cosmetic, you need to focus on those facts and health problems that they cause. alot of people wait untill they need plastic surgery before they even start to document these problems. it is very important to show a 'HISTORY' of on going health problems from the ever begining that are caused by excess skin. if you can go to your primary care doctor and get them to document a problem, then take that to your plastic surgeon to attach to your packet that they send in to the insurer this might help. insurance companies don't care that you have to move the skin to do daily things....only that they cause a medical problem like numbness ect.....
   — franbvan

May 24, 2004
just like WLS - if your 'denied' APPEAL. My TT had to go to level two. My Breast reduction was denied by Aetna; BUT thankfully my employer has the 'last' say in approval and they overrode Aetna and my breast reduction is now being covered.
   — star .

May 25, 2004
Not much of a question here. Just I am in the process of waiting for hopeful approval for a panni by UHC also. Really worried of being denied too. My surgeon said they wanted to have all their ducks in a row when they submitted, also I wrote a lengthy letter and enclosed some articles about tummy tucks after massive weight loss, hopefully it helps. Awaiting results from UHC. I plan on appealing if denied. If I can help with some of my articles let me know. Patricia 9-30-03 314/190/183 past goal
   — pateblkbrn

May 25, 2004
I just had the tt done last week. BCBS required me to be near goal weight and with having a hernia to fix at the same time they approved it. I did have to send additional pictures to them showing the hang over the pubis part. Your insurance company may drag its feet if they think that you would have to repeat the surgery later due to more skin issues. Continue to appeal to them and never give up. Once they think that you are persevering and will not relent they will change their minds. I called them every day and sometimes twice a day checking for approval and they documented it. I think I talked to every representative they had and in fact got on a one to one name basis with one of them. She continually checked with them herself and I sent my pics to her directly. Good luck and keep on them.
   — classydame1

May 26, 2004
Gina, I too have Cigna... its very difficult to get approval. I'm having a revision and did get approval.There is a yahoo group, [email protected] ,that has a multitude of info on how to get approved. If you need additional help, please contact [email protected]... Hope this helps... Linda in SC
   — Linda C.

May 29, 2004
Don't give up! File an appeal (usually called a grievance when initiated by a member) with your insurance company - check your member handbook for their procedure. And if they deny it again, file another one (sometimes called an appeal of a grievance)! And if that doesn't work, write an appeal to your state Department of Health and/or Department of Insurance. Check your state's guidelines to find out what they require. Make sure that your doctor includes all types of documentation - including medications used, their dosages, and for how long -- your complete chart, if possible! Call and find out exactly why your insurance company denied you and see if you can do something to fulfill the missing requirement. But don't let them get away with it. From your description you have a definite medical necessity - not just cosmetic reason - for having a panniculectomy and/or abdominoplasty. And insurance companies usually HAVE to pay for medically necessary surgeries if they have documentation to support that necessity! Good luck!
   — IleneRachel