Question:
What can I do now?? Insurance denied me an external review!

My insurance company denied me an external review stating that my need of a abdominoplasty was a "complication" of a non-covered service (RNY). What can I do? I have letters from doctors stating that this is NOT COSMETIC SURGERY!! I am thinking about contacting a lawyer. Do I have a chance??? This is so heart-breaking!! Thanks for any replies!!    — dixie24fan (posted on December 17, 2004)

December 17, 2004
They are not saying you cannot have it because it is cosmetic surgery. They are saying that they do not cover WLS and because it is a complication of WLS they won't cover it. I would definitely see additional advice however be careful you don't spend as much in lawyers fees as it would cost for the TT. The bottom line is you could have lost the weight in any number of ways and still had the same end results. The excess skin is not a result of WLS it is a result of massive WL. There is a big difference and maybe this needs to be pointed out to them. <p>I'm assuming you were a self-pay for your WLS or had it done under a different insurance, based on their denial. If your policy is part of a group plan from work you could approach your employeer. If it is a self-insured plan then definitely talk to HR and see if they will overturn it. This is unfortunately one the potential cost side effects of being self-pay. If anything can be attributed to the WLS they will do it and deny coverage. We always have 3-4 plans available to us through work and one of them will cover WLS the other HMO's won't. But because I had it done under a covered plan, if I switch to a plan that does not cover WLS in the future, they will be forced to cover any medical problems related to the WLS. This I have in writing from the administrators of our group policy. Last year one of the HMO's tried to tell me nothing would be covered so I went to the group insurance administrator and they sent a letter to all plans indicating that indeed they would have to cover anthing as long as the surgery was done under one of the cover plans. For me this is a huge incentive to never change employers again. Good thing I like my job - at least most days. LOL Good Luck!
   — zoedogcbr

December 17, 2004
I don't think they can deny the review. You have a right to every appeal available. Contact the insurance commissioner for your state and file a complaint right away and keep trying. good luck.
   — catleth

December 17, 2004
ah this is a new one. Did you self pay your RNY??? What you wrote is that they didnt deny you saying its cosmetic - they denied you stating its a result of you loosing weight from the RNY - which THEY state they do not cover. Now if you have the same insurance and you self paid... I think this would require a lawayer, cause techniclly they are right it became medically necessary due to your RNY. BUT if you had your RNY covered by another carrier, and switched to this and they dont pay for the RNY I would say tuff Sh*t and contact the lawyer since you are not asking for a procedure thats not covered and even if they didnt pay for the RNY the adbmonisoplasy should be covered... Did you self pay???
   — star .

December 19, 2004
Thanks for all the fast responses. I was covered by another insurance company, not the current one I have. My employer changed insurance companies since I had the RNY. So an insurance company did pay for my surgery. Thanks everyone!!
   — dixie24fan