Question:
Need Help! plastic denied

I just recieved my denial letter for my Mammoplasty and Panniculectomy. I am not going to worry about the breast right now. But would like help knowing exactly how to respond. Here is there reason for denial on the panni: The plan considers Panniculectomy reconstructiveand not cosmetic only when the pannus causes recurrent,severe intertigo/cellulitis that requires treatment with an oral antibiotic and is unresponsive to conservative treatment including adeqate hygiene and topical anti-infective medications. Such a showing is not made on the records submitted for review. In addition,per the morbid obesity gudelines SUR6710: Significiant weight loss following surgery for morbid obesity can lead to redundant skin and fat folds in varied anatomic locations (e.g.,breasts ,medial upper arms,medial thighs,lower abdominal area).Surgical removal of redundant skin and fat folds is generally considered cosmetic and is not covered. Coverage my be considered in patients with stable weight following surgery for morbid obesity,when the redunant skin or fat folds cause recurrent,sevee intertrigo/cellulitis that requires treatment with an oral antibiotic and is unresponsive to conservative treatment including adequate hygiene and topical anti-infective medications. Request for prior plan approval for panniculectomy is denied. The surgeon submitted letters from him and my gastric bypass surgeons stating that I have recurrent intertrigo. And that I have been treated for it. It sounds like they want to approve just want more documentation. I have BCBS of Nc Blue Care. If anyone can help me it would be greatly appreciated.    — jenn5173 (posted on March 8, 2004)

March 7, 2004
Original poster here. Just talked to the surgeons office.They are going to appeal the panni. But I was wondering if I should send in a letter from myself too. Or just let them handle it.
   — jenn5173

March 8, 2004
Hi. Dont despair too much....I think about 40% of denials we get eventually are reversed. It's important to add NEW materials to the appeal...not just re-send the original data. Visits to you family doc for the skin problems go a long way in supporting the claim of intertrigo, as do prescriptions for the condition. Sadly, I am encountering more resistance on the part of INS companies in approving these types of surgeries. No doubt they are reconstructive/corrective but they are sometimes borderline in terms of causing serious health problems. Good luck !
   — DrL