Question:
2 Denials for Reconstructive Surgery - Retained an Attorney - HELP!

I have been denied twice for reconstructive plastic surgery, specifically, hernia repair with abdominoplasty, and brachioplasty with thighplasty. <b>I AM INFURIATED!!</b> I meet all the requirements for "reconstructive vs. cosmetic", and have all the medical problems that document plastic surgery as medically necessary provided by three different plastic surgeons, my PCP, my OB/GYN, and my bariatric surgeon. To add fuel to the fire, a coworker upstairs had an abdominoplasty covered three years ago. No changes in the plan.<br><br>So, I have retained an attorney. I want to be cautious, however, because I don't want to wind up spending as much in attorney fees as I would by paying out of pocket for the surgeries. I have a preference for one surgeon, but if I can't get it covered by insurance, I'll have to go with my second choice due to cost. Another kink, is I have only TWO times available this year due to my hectic schedule with family, grad school, and work.<br><br>If anyone can give me some additional tips on what else I could <b><i>POSSIBLY</i></b> provide to have this overturned as quickly and as cost-effective as possible. Many thanks in advance.    — [Deactivated Member] (posted on April 24, 2001)

April 24, 2001
What does the denial specifically say? Is it that they wont cover all or just one piece they don't like etc? How abotu trying to auth each procedure separately like was stated above... If you meet the requirements then something else is going on and your denial should state exactly what that is. Holler if I can help at all.
   — Dawn R.

April 24, 2001
Additional info: Neither I nor my surgeon have received written documentation of either denial. Quite convenient, given I have no right to sue until I receive it. The procedures were requested to be done separately. All they will tell me is that is isn't medically necessary.
   — [Deactivated Member]

April 24, 2001
Check w/ your state insurance comissioner and find out what your rights are.. you have to get the denial in writting.. this makes no sense. Not only do you have a right to get that information you should also be able to find out what their criteria is specifically. I'll try to help in anyway I can let me know what I can do!
   — Dawn R.

March 19, 2007
You should have the financial responsiblity for your own cosmetic surgery. but for the fact you were not formerly obese you would not need these procedures. Therefore, you ultimately are responsible for the shape your body is in now and not others. who pays for your grad school?
   — careforyou

May 7, 2007
I don't agree with the one poster that you should pay because you were formerly obese and caused that obesity. What if the insurance would not cover plastic surgery for a skin cancer on your face, for instance, saying that if you had stayed out of the sun you would not have caused the deformity resulting from removal of the skin cancer. No, insurance is responsible to pay if they state in the policy that they will pay based on certain criteria. If a coworker had the same thing done, then I would find out what the difference between me and the coworker to see if there was something more I needed to do to be qualified. Insurance companies certainly can't pick and choose who they allow to cover if the policy states clearly what it will cover.
   — Sharon J.