I have my first consult for plastics! Questions....

[piercedqt78 658]

I contacted the office of the doctor that came highly recomended by my daughter's peds group (they use them for reconstructive surgery when needed) and made an appt to see them on wed. I have a huge packet to fill out and they suggested that I make a list of questions and bring that with me, and also to call my insurance and get their requirements for coverage. I did, and they directed me to a medical article on their website. It has a list of requirements, and I think I meet them all. But I'm not sure. Here is the exact wording:

Indications and Limitations of Coverage

Coverage for cosmetic services is determined according to individual or group customer benefits.

Corrective facial surgery will be considered cosmetic rather than reconstructive when there is no functional impairment present.

An indication or a diagnosis of "pain" may qualify as functional impairment.

Psychiatric indications do not warrant payment for cosmetic surgery when no functional impairment is present. However, severe psychological impairment, appropriately documented, can be classified as "significant functional impairment" on an individual consideration basis.

In cases involving psychiatric disorder or involutional changes due to aging, the claim should be accompanied by a report from a psychiatrist who indicates a definite psychiatric condition relevant to the condition to be corrected by the surgery and that the proposed correction is likely to be of significant help in treating the psychiatric problem. These services require medical review prior to payment.

Some common procedures which may be potentially cosmetic may also be considered reconstructive. The guidelines in this policy should be used to determine whether those procedures are cosmetic or reconstructive. There may be procedures other than those included in this policy which could be performed for either cosmetic or reconstructive purposes. These procedures should be reviewed on an individual consideration basis and classified as reconstructive surgery only when there is documented functional impairment.

The following procedures are considered reconstructive and medically necessary when all of the procedures specific guidelines below are met:

Abdominoplasty, Panniculectomy ("Tummy Tuck")(15830, 15847, 17999), when all of the following criteria are met:

1. Preoperative photographs document that the panniculus or fold hangs at or below the level of the symphysis pubis; and
2. The medical records document that the panniculus or fold causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs or remains refractory to appropriate medical therapy (including appropriate prescription medications) over a period of three (3) months.

NOTE: The patient must be at least 18 months postoperative following bariatric surgery.

NOTE: Report procedure code 15830 (Excision, excessive skin and subcutaneous tissue [includes lipectomy]; abdomen, infraumbilical panniculectomy) when performing a panniculectomy. Report procedure codes 15830 and 15847 (Excision, excessive skin and subcutaneous tissue [includes lipectomy], abdomen [e.g., abdominoplasty] includes umbilical transposition and fascial plication) when an abdominoplasty is performed with a panniculectomy. Procedure code 15847 should only be reported with procedure code 15830. When an abdominoplasty is performed without panniculectomy, report procedure code 17999 with a description of the service.

Place of Service: Outpatient/Inpatient

Abdominoplasty/panniculectomy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

https://secure.highmark.com/ldap/medicalpolicy/wpa-highmark/S-28-026.html

I have lost 130 pounds, and have a ton of skin that just hangs everywhere. I have pain when I sit or lay down from my skin "bunching up" and I also have issues with rashes, and ulcers. On the 1st requirement, it states that the "panniculus or fold hangs at or below the level of the symphysis pubis"

Is that when I am standing upright, or when I lean forward? Also I had my sleeve last may (less than a year ago) but I was originally banded 9 years ago, I'm hoping they will consider that. I also need my thighs taken care of, but there are no guidelines for that, so I guess we will see what they say about that.

Any body have a list of questions that they have asked, or that I should be looking into asking? I have never done this before, and am a bit lost. I was also happy that they will be doing the consult free of charge, and I am welcome to have a consult with each and every surgeon in the office, at no cost to me. They encourage you to see them all, one at a time to make you the most comfortable.

Also should I be prepared for them to take photos of my in my bra and panties? The only thing I know about plastic surgery is what I have seen on TV/Movies. I know that's just sad, but I'm more of a tomboy than I care to admit and before all of this wouldn't have considered plastic surgery at all.

[Laura1014 28]

I am a 10 year Lap Bander. I had it removed last month. now will have sleeve or plication hopefully in the next 3 months or sooneer. I read you had Lap Band. I did really great for a decade, but last 5 years no real fills...and it slipped...low..way low. Not I have packed on 30-40 pounds and i am running to Tijuana and back and to the moon if I have to ...just to get a sleeve or Plication.

I had an Abdominaplasty done In Dom. Republic 3 years ago (fantastic surgeon), along with Breast implants (get under muscle..never above) I had such hard time and plenty of crap from my insurance here in Florida. I am a Consultant for Physicians in the State and they all told me to just save and do my surgeries cash. Insurance just gave me such headaches. I gave up.I travel now from Orlando to Miami every week due to my job, and after I loose my weight again, I wont bother with my insurance. I hope you have a good carrier and understanding people. Your insurance carrier should pay for extra skin removal, and anything that is excess skin. If they don't....there is other alternatives if you can save a little at a time and have them done by areas,

Laura in Orlando.

[piercedqt78 658]

After my consult the insurance co-oridinator told me that she was going to flag my chart, and not submit anything until they had my lap band surgical notes (I have them, and took them to my GP to submit with everything else), and also the notes about the skin rashes, and pain from my skin "bunching up" when I try to lay down, or when I sit. Well they didn't wait, and submitted my paperwork and listed that I was only 10 months post-op, and no notes about my skin issues, and pain. So I was of course denied, and I'm only allowed 1 submission, and 2 appeals. So they just burned through one of my chances to get this covered. I got the denial letter on Sat, and called today. The office manager called me back this afternoon, and was like "oh, I'm so sorry this happened" I asked if they could call my insurance and tell them it was a paperwork error, or that they had mixed up their info, she said she would talk to the staff that was involved and get back to me tomorrow. I'm super pissed, they just reduced my chances of coverage by 33%. Now I'm worried that they are going to go through everything submitted with a fine tooth comb, and pick apart my appeal. I spent the weekend crying, and now I have spent today fuming. What would you do?

[CBT 450]

After my consult the insurance co-oridinator told me that she was going to flag my chart, and not submit anything until they had my lap band surgical notes (I have them, and took them to my GP to submit with everything else), and also the notes about the skin rashes, and pain from my skin "bunching up" when I try to lay down, or when I sit. Well they didn't wait, and submitted my paperwork and listed that I was only 10 months post-op, and no notes about my skin issues, and pain. So I was of course denied, and I'm only allowed 1 submission, and 2 appeals. So they just burned through one of my chances to get this covered. I got the denial letter on Sat, and called today. The office manager called me back this afternoon, and was like "oh, I'm so sorry this happened" I asked if they could call my insurance and tell them it was a paperwork error, or that they had mixed up their info, she said she would talk to the staff that was involved and get back to me tomorrow. I'm super pissed, they just reduced my chances of coverage by 33%. Now I'm worried that they are going to go through everything submitted with a fine tooth comb, and pick apart my appeal. I spent the weekend crying, and now I have spent today fuming. What would you do?

I would let it play out between the office and insurance. I might write a letter to my insurance company and explain the problem created by the doctor. Just so it's on record.

Then, I'd research my state's insurance commissioner.

[piercedqt78 658]

Problem is my Insurance is not in my state. I'm waiting to see what she says when she calls me back tomorrow.

[CBT 450]

Problem is my Insurance is not in my state. I'm waiting to see what she says when she calls me back tomorrow.

No Doctor's office wants to hear that you are calling the insurance commissioner. The breadth and depth of the commissioner's duties can vary by state. That's why I'd research it. I only know my state. Our commissioner is all about protecting the insured.