Question:
Anyone have BC/BS PPO Pay for Abdominoplasty for 2005?

4 yr post-op RNY, still trying to get BCBS to pay for abdominoplasty, they've said I don't meet their medical criteria for the surgery, does anyone know what their medical criteria is? When I lay on my side it looks like I have a watermellon pulling away from my waist and hips, when I bend over it looks like an utter without teets, my puffy panni flows onto my upper thigh about 4". I asked my doc why this is as I thought I had no muscle holding in my abdominal organs. He said some post-op's have loose hanging skin and others like myself have about 1" of fat underneath the skin that won't go away with exercise or diet, he said the only way to get rid of it is to have an abdominoplasty where they could remove that layer of fat. I'm working on letters of med ned from my RNY surgeon, a neurosurgeon who has performed 2 recent back surgeries, an anesthesiologist who is treating lumbar disc compression by pain mgnt, a psychologist as I feel physically un-attractive, a nutrictionist, my primary doc who prescribes cream for my panni rash during hot weather days and pictures. Need all the help I can get, anyone have med ned letters willing to share for 2005? Any web sites out there which offer assistance re: how to get approved? Again my big question? is it more difficult to get TT approval from BCBS for 2005 than the previous years? Any info greatly appreciated. Thank you for your support.    — Barbara M. (posted on March 29, 2005)

March 28, 2005
I had my abdominalplasty in August 2004. BCBS Community Blue PPO gave my surgeon pre-approval because I had lost over 100 pounds and he also submited photos and medical problems like yeast infections under the folds. BCBS paid everything, but my $400 co-pay for the hospital. I am not sure if they have changed the criteria for 2005, but you might want to call them directly and ask what documentation you need. Good luck.
   — ckreh

March 29, 2005
I also got coverage but again it was in 2004, but it was under a PPO plan. I got full coverage for a full extended abdominoplasty done in 2 surgeries. Not all skin involved could be removed in the first surgery due to my waist being very anchored and not being able to pull all the excess skin down and cut off like normal. <p>I had similar issues as you. My approval was based on severe degenerative disc disease in 4 discs in the low back. I never had any skin issues. I also submitted with a letter from the Neurosurgeon and PS and they did not approve. But in my denial letter it said that it appeared to be cosmetic but they would agree to evaluate again after I was done losing and that I should resubmit with an orthopedic evaluation and recommendation and new pics. The one pic the PS sent was horrible and hardly readable. I was ticked at first about needing the ortho eval but did it anyway. Fortunately the ortho I saw was totally supportive and wrote a great letter that said there was no question that removing the skin would help my back condition. It would not fix it but would allow it to improve as much as possible and also allow the stomach muscles to be tightened which also factors into the back. He also reminded them that anti-inflammatories are not an option as a PO and that I had been using epidural steroid injecitons as well as oral steroids occassionally to deal with the problems since about 1997. I also had the neurosurgeon write a more detailed letter stating why he did not want to do surgery at this point. I then wrote my own letter and in there clearly stated that I knew it would not fix things but that it was a logical and cost effect way to manage this medical condition and that the hope was that it would help me to totally avoid surgery or at least delay it for many years. I then had my friend take really good pics and I delivered it all to the local BCBS service center and had approval the next day. Only in my letter did it mention the need to have the surgery done in two stages. The PS's note made a slight mention yet he never asked for approval that way. I got approval for both stages and did not have to go back after the first operation and seek approval for #2. Which is good, because truthfully it would have been a lot harder to call that medically necessary versus cosmetic. It looked very strange because it could not all be removed, but really did not affect my back. It was clear that the first reviewer wanted to approve my request but needed some more teeth to justify it. I have never had a denial letter from BCBS lead me down the path to approval, like this one did. It might help to take the same approach with an ortho eval. The bottom line is in their mind if it's all neurologic then removing the skin won't help. They wanted to know that something "mechanical" would be fixed or significantly improved. An ortho is based on mechanics, so that is why they wanted a letter from him stating that this would improve things. And truthfully it has. My back is rarely an issue with me any more. If I do too much standing then I can have some leg/foot numbness in my right leg because of sciatic compression, but other than that I am soooo much better. I hope some of this info can help you!
   — zoedogcbr

March 29, 2005
in 2004 I got approval for a panniculectomy based on photos submitted by the plastic surgeon. the only criteria that I know of was pannus covering private area. I only had 1 minor yeast infection in my belly button that I did not even go to the doctor with, treated my self over the counter with monistat. I had to pay the balance to get the other stuff done. Everything (pictures included) had to be submitted directly by the Dr. tho.
   — **willow**