Question:
I have to write a appeal letter for reconstructive surgery....

This will be my second appeal for a panni, thigh/breast lift and arm reduction. I have Ohio Med, Medical Mutual, and in the benefits section it says that they cover the above procedures if its medically necessary. My question is i've submitted pictures, office notes and a letter from my surgeon and primary doctor and im still being denied for the services because they are saying its cosmetic. I been experience back pain/neck and shoulder pain as well as rashes between the flaps of skin, thighs, and bra areas. I called my insurance company yesterday and now they are sayin that i need a letter from my doctors saying that if i dont have the skin removed the problems will keep occuring. Has anyone else ever had to do this to get approved? I mean, i thought thats what the office notes were for...any insight would be appreciated... Thank you, Nicky    — Nicky-28 (posted on February 9, 2005)

February 9, 2005
Were I you, I would do some research, and find the best attorney around that deals with this specific insurance matter. The money invested would be a fraction of the cost of the surgery.
   — lindarodham6

February 9, 2005
You should have had your pcp write a letter of medical necessity, stating your problems and that reconstructive surgery is the only way to eliminate the problems. The insurance co. doesnt want to have to decipher the med notes they just want the letter, and then if there is a question they will over look the notes. So have your pcp write a letter of medecial necessity and fax it to the insurance co. If you meet the requirements, ie...pannis hangs below the mons, lost at least 100# from wls, weightloss has stablized, and that it is medecialy necessary you shouldnt have any problems. Theighs, and arms are usualy considered cosmetic, and as are breast lifts, but a breast reduction, with at least 500cc removed from each breast will usually, qualify. Good luck to you, call your insurance co and ask for spacific requirements for reconstructive surgery. Rosemary
   — wizz40

February 12, 2005
I think your doctor (PS) should lead the way to get the surgery approved, as they are the ones being paid for it. Supporting documentation from your PCP and yourself also help. They want PROOF of medical problems you have had because of excess skin for SOME PERIOD OF TIME. That means office visits, prescriptions for rashes, back pain, neck pain, therapy...anything related to those problems. You sound like a "chip shot" for approval.
   — DrL