Completely Devistated....vent

[Nikki Riviotta 33]

For several months now I have been getting rashes where the skin hangs around my stomach area. I talked to my primary doctor and he referred me to a plastic surgeon. (We are military so we have Tricare for insurance.) I go in to see the surgeon and she says she never has problem with Tricare approving panniculectomy surgery after weightloss if 1. The patient has lost 100 pounds or more or 2. is getting rashes due to the hanging and sagging skin so she felt I was a shoe in for the surgery approval especially since we are able to get photos of the rash to submit to insurance as well. Today I get the letter in the mail that Tricare has denied my surgery. That they did not deem it medically necessary based on Tricares criteria, but I was given the option to appeal. That is exactly what I did. I wrote them an appeal letter stating all the reason I NEED this surgery. Basically I am tired of hurting from the rashes and tired of the hygiene issues that come with this saggy skin. When I initially applied for the lapband they denied that too and I at that time also wrote my own appeal letter and wouldn't ya know it they approved it. This time I stressed how much work I put into the weightloss. I have worked so hard to get here. Now I am in pain and need to have this done, but I am unsure of how this will go for me. The abdominoplasty will cost me $7500 out of pocket and that is the route I am gonna go if the panniculectomy is not approved at all after all appeals have been exhausted. But wow thats a lot of saving for a one income family of 5. I may have to get a part time job too, with also being a full time student.

I keep reminding myself that I have been so blessed already and that insurance has done so much for me just by accepting my appeal and allowing me to have the surgery done. I am so appreciative of what they have done to help me. I guess it was just kind of a slap across the face when they basically said it doesnt matter to them how much pain I am in, this procedure is not medically necessary, and also forget all the hard work you have put into losing your weight, we still wont help you take care of this....

I will continue to pray about this, I know that what is meant to happen will. I am blessed to have come this far and no matter what I will have the surgery done eventually. It may take me a couple of years to get all the money but I will get it done. I just may have to come to terms that it may be later rather than sooner.

Thanks for listening to me vent. I feel much better. Have a blessed evening everyone!

[Cazzy 725]

I hope u get a positive outcome from your appeal, but dont give up the fight whatever u do . As a last resort i would definitely seek the opinion of a Dermatologist. Someone who can give a professional opinion regarding the skin rashes their long term effects on your skin and the cost of continually treating such rashes etc etc.

If necessary even seek a psychologists opinion on long term pain, self esteem, depression etc.. you have to fight fire with fire and sometimes these large corperations need to know u arent going to just 'go away'

I know someone on this forum mentioned a lawyer who specialises in Insurance appeals .. i will try and find the thread for you.. it might be an idea to go that way too ..

good luck, i am coming up to needing my skin removed to and although i am in the Uk my Health serivce here will also want to make me go away, which i will not be doing

[Caribear 184]

I'm so sorry you're having to deal with this, Nikki. I agree, appeal appeal appeal! And I know that your first instinct is to take it personally, but just remember that it's not about that for them. They are in the business of denying every claim that they can, whether it is necessary or not, because denials usually make people just give up. As unfair as that may be, that's how insurance companies work. I have heard stories about how at some companies, the first decisions are sometimes made simply based on the type of procedure, not on the actual medical need. You are doing the right thing by appealing.

On a more positive note, congratulations on your success! I will pray for you too. God is good, and He will provide for you.

[Nikki Riviotta 33]

Thank you Cazzy! I dont plan to give up until I try everything Good luck to you as well! Show that insurance company who is boss!

[Nikki Riviotta 33]

I'm so sorry you're having to deal with this, Nikki. I agree, appeal appeal appeal! And I know that your first instinct is to take it personally, but just remember that it's not about that for them. They are in the business of denying every claim that they can, whether it is necessary or not, because denials usually make people just give up. As unfair as that may be, that's how insurance companies work. I have heard stories about how at some companies, the first decisions are sometimes made simply based on the type of procedure, not on the actual medical need. You are doing the right thing by appealing.

On a more positive note, congratulations on your success! I will pray for you too. God is good, and He will provide for you.

Thank you! I was told that our insurance denies the first time for lapband too, that the ones that appeal it show to be the ones that truly want it, and seems that may be true since they approved it with my appeal. I really hope that is the case here too. You are right God is good! He is my rock in all that I do and I really dont think he brought me this far to not be able to competley finish what I have started here. I also dont believe that he would want me to live in pain either especially when its this easy of a fix. I am a firm believer that if he brings you to it, he will get you through it Bless you and thank you for your kind words

[gottobeme 81]

I agree with all of the above posts and also wonder are the rashes likely to lead to infections? That is something I think you should consider including in your appeal.

[twi 40]

Sometimes it's all in wording. Call your insurance co and ask them to send you all criteria needed for approval of that surgery. I'm in med field and we have these problems getting pt approved for med nec procedures until we get the info from insurance to find the buzz words they are looking for. You would be surprised what one little word different in your wording will get you. Good luck to you!

[Nikki Riviotta 33]

I agree with all of the above posts and also wonder are the rashes likely to lead to infections? That is something I think you should consider including in your appeal.

Yes there is a very good chance of skin breakdown, skin infections, sores and even yeast infections under the skin. I used to work as a CNA and I would see that type of thing all the time. So did include that in my appeal letter

[sam1017 0]

Yes there is a very good chance of skin breakdown' date=' skin infections, sores and even yeast infections under the skin. I used to work as a CNA and I would see that type of thing all the time. So did include that in my appeal letter <img src='http://www.bariatricpal.com/public/style_emoticons/<#EMO_DIR#>/smile.png' class='bbc_emoticon' alt='' />[/quote']

So did they approve you?

[Cazzy 725]

Yes let us know how it all went Nikki !

[bandbun 9]

Yes let us know how it all went Nikki !

Interested to know too.

[Annette 9/2012 15]

I am so sorry that your insurance company denied your request. Yes, yeast infections are most due to warm most areas and certain areas not being able to be kept dry. Unfortunally- not many insurance companies do request this kind of surgery. This is the "nasty part of the end result of WLS which depending on the amount of weight that you loose and skin tigor exactly how much loose skin a person will have. I am at the begininng of my journey and my doctor advised me of this and warned me that any amount of weight loss + 80 lbs could result of sagging skin and she also indicated that "warning" "most insurance companies do not cover abdominal tucks or Lipo suction. If you view most pictures of people who have lost a significant amount of weight -usually sagging skin happens. Good luck.

[Nikki Riviotta 33]

UPDATE: My first appeal was denied. The letter said I didnt have enough documentation . I also called and spoke with a woman at my insurance company that said they want wls patients to be at least 18 months post surgery. So That put me out until September. From April to September I went to the doctor for every rash. In August I began to develope severe back pain much like what I had before i had a breast reduction. So the doctor put me in physical therapy. Even my physical therapist agreed I would greatly benefit from having the surgery done. In October I obtained all of my medical records and by end of november it was submitted. They denied it in less than 24 hours. My surgeons office looked into it and said that for some reason only 15 out of 50+ pages that were subitted were received. I appealed stating this in my letter. It took them less than one week to deny that appeal too stating that they reviewed EVERYTHING and that is just wasnt enough to make them cover it. I at that point decided to pay out of pocket. My husband and I were gearing up do what was necessary. Then this past tuesday the surgeons offfice called and said she got and approval over the phone. I received the new approval letter yesterday and it stated that the remaining 33 pages they didnt get were due too FED EX never delivering them. The new notes were then faxed and an approval was given stating I met all criteria. So I am scheduled for Feb 5. I am beyond excited. But nervous too, as I always am when I am going to have a big surgery. SO Thank you for all the support and prayers. God has taken care of me. Please pray that I have a successful surgery with no complications and an easy relatively quick recovery because I have a 3 year old that is not going be happy if Mommy cant play for very long LOL

[babykins529 189]

Congrats! I'm glad all your hard work and perseverance paid off.

[Nikki Riviotta 33]

Congrats! I'm glad all your hard work and perseverance paid off.

Thank you!