Question:
Approved for TT by insurance without hernia or rashes? How?

I have been denied for breast reduction and abdominoplasty by Aenta. I am trying to figure out how and when to file an appeal, especially for the abdominoplasty. It seems Aetna and others seems to cover even without hernias/rashes or am I wrong? Pannus is also complicated by having had 4 c-sections! Any ideas would help as I am 14 months post-op RNY, -116 from 266 to 150 pounds and feeling great! Thanks1    — Molly S. (posted on August 14, 2002)

August 14, 2002
Use NAIR to create a rash :) Then take a picture of it or have your doctor take a picture of it. Do this several times over a 5 month period. *THEN* submit the paperwork again for abdominoplasty. Heard of others doing this....
   — Kym L.

September 22, 2002
hey gal, I also have aetna.. here is the critera for approval; Coverage Policy Bulletins Number: 0211 Subject: Abdominoplasty/Suction Lipectomy/Ventral Hernia Repair Policy Aetna covers abdominoplasty / suction lipectomy according to the following criteria: Panniculus hangs to or below the level of the pubis; and The panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs or remains refractory to appropriate medical therapy over a period of 3 months Coverage may be subject to individual case review and prior approval in plans with such provisions. Aetna covers repair of a true incisional or ventral hernia. Aetna does not cover an abdominoplasty to repair a diastasis recti, defined as a thinning out of the anterior abdominal wall fascia, because, according to the clinical literature, it does not represent a "true" hernia and is of no clinical significance. Coverage may be subject to individual case review and prior approval in plans with such provisions. When documentation of the medical necessity of a ventral hernia repair in order to distinguish it from a purely cosmetic abdominoplasty is requested, Aetna requires documentation of the size of the hernia, whether the ventral hernia is reducible, whether the hernia is accompanied by pain or other symptoms, the extent of diastasis (separation) of rectus abdominus muscles, whether there is a defect (as opposed to mere thinning) of the abdominal fascia, and confirmation of the presence and size of a fascial defect by office notes, and either ultrasound or CT scan of the abdomen.
   — msjmcalpin

September 23, 2002
I was approved by United Health Care on the basis of back pain from severe muscle separation (distasis recti) and the need for reconstruction to restore a normal appearance following the loss of more than 100 pounds. They also approved breast lift without a rash. Denied thigh lift, though that was eventually overruled. All groups are different and much depends on how the insurance is structured. Mine was with an employer that was a large self-insured company, so the company set the rules, not UHC. Good luck! hugs, Ann RNY9/10/99 260/130
   — [Deactivated Member]