Question:
Plastic surgery denial letter....Who writes the appeal letter?

I just recieved my first denial letter from the insurance (bluecross/blueshieled..cont. airlines) My dr. wrote the first letter with the "infamous" photos, so my question is this....Should he write the appeal letter or should I? I have lost apprx. 160 pounds and the back of my legs/thighs are horrible. This is not cosmetic for me and I've check around and found that this procedure usually runs around 10,000...Help!    — rhonda R. (posted on May 28, 2004)

May 28, 2004
writing an appeal letter is going to most likely be up to you. I have heard of rare cases where the Gastric Doc will but not a plastic surgeon. Don't waste your appeal process, throughly investigate and understand their grounds for denial and make your best case. Before appealing it might be worth your while to find out if they have medical guidelines for the abdominoplasty/panni. The first time I filed for approval I lost all my appeals. Got the insurance company's medical guidelines - followed them and got approved 6 days after they received my PS pre-determination letter. Good luck
   — bbjnay

May 28, 2004
Keep trying It took 5 appeals and then to the insurance commissioner to win keep going. And good luck to you
   — Tammy P.

May 28, 2004
IF your PS is like most.. YOU will have to do the appeal process.... most PS cant be bothered.
   — star .

May 28, 2004
I have to disagree. The PS should be writing the appeal. You should be getting add'l info from other DR's you have seen IE: chiropractor/back pain/headaches, GYN/MD rashes It would help for you to also write a letter stating all of your symptoms along with the appeal. I worked medical review for PS for 6 years for a well known company. The appeal will go to another DR and appeal is Peer to peer review, which means the reviewing DR should be a PS and speak to your PS to get the facts. Best of luck!
   — ZZ S.

May 28, 2004
I forgot to add... insurance companies review based on medical necessity, so that means only the PS and other providers can provide this. You can give your opinion, however in the insurance world you aren't an expert. What was the reason for denial?
   — ZZ S.

May 29, 2004
Well, I have been denied twice. I am on the second level of appeal.. The first letter the PS wrote.. The second letter I wrote along with another doctor ( my gastric bypass surgeon) saying I need the surgery.
   — Catherine B

May 29, 2004
In my experience, the doctor (and sometimes a representative for the patient) must file an appeal. Each INS company is different. The appeal should contain NEW information...like "objective documentation" of your problems. It's not enough for your PS, PCP, or for that matter anyone else to simply SAY you have skin issues, pain, rashes, etc. It must be documented as an office visit for that problem, and a treatment or prescription for that problem must be given. Sometimes they want 6 months of this before approving surgery.
   — DrL