Question:
Pre-determination sent for doctor reivew plastics

I had consult with plastic surgeon on June 8, 2004 they sent pre-determination letter in the very next day and I still havent heard anything. My plastic surgeon's letter stated Patient was seen today for plastic surgical consultation regarding abdominal wall weakness and abdonimal panniculus. The patient is a 30 year old female that is 5'7" tall, weighing 146 pounds who upon examination presents with significant overhanging abdominal panniculus with associated sub panniculus intertrigo. She also has a wide rectus diastasis, which is causing significant abdominal wall weakness. The abdominal panniculus and its associated weakness, severely limits her ability to exercise which she needs for continued weight loss and general health maintenance. The patient has: 728.84 diastasis of muscle-diastasis recti (abdomen) 695.89 Intertrigo 278.1 Localized adiposity The patient needs: 15831 Excision excessive skin and subcuntaneous tissue (including lipectomy)abdomen(abdominoplasty) 49560 Repair initial incisional or ventral hernia, reducible The purpose of this letter is to request pre-authorization for this medically necessary procedure. Does this sound like a good letter? I called the ins company last wednesday and they tole me it had been sent to a doctor for review that the nurse there didnt make a decision so she sent it to a doctor. Is that a bad thing? Any info appreciated.    — Carrie W. (posted on July 12, 2004)

July 12, 2004
Carrie, I don't know if I would worry or not. It really depends on what your insurance covers and what it doesn't. If they view this surgery as reconstructive, and probably the MD will make the call, you will likely be okay. It sounds like a pretty good letter to me. I hate to say this, but in the insurance company where I work, I, as an RN, cannot deny anything. I have to send it to the Medical Director. However, it may be a different protocol for your insurance company. Perhaps everything is reviewed by a nurse, and if it is pretty "cut and dried" she can send the request for a denial, but if she has questions, it goes to an MD. You might want to call the insurance comapny back and ask if every request goes to an MD, or why it goes to an MD. Good luck!
   — koogy

July 13, 2004
Wait and see.. EVEN with a great letter - insurances like to 'deny' PS on the first go around.... kinda like WLS.. Just appeal.
   — star .