Panni denied by HMO

[onmyway11 43]

My panni was just denied by insurance. I have a *** and needed to get a reference from my GP to see the plastic surgeon then approval from my GPs medical referral bc the doctor my Bariatric surgeon recommended was not in their office (eyeroll). I have lost 105ish lbs and I need one!

I’m wondering a few things and hoping you all can help me figure this out.

First I’m wondering if I got denied bc the surgeon I went to was not out of my GPs office? They had one to give me but when I researched him he was a hand doctor who did plastic surgery also.

Secondly I’m wondering if the plastic surgeon I went to was ridiculously expensive and that’s why it was denied. Tummy Tuck was 12,500 and breast lift was 12,000. I know only the panni part is covered but this surgeon does both for same price.

Thirdly and most importantly I’m wondering what my rights are to appeal something like this.

I plan to call in the morning but wanted to get my ducks in a row and have a clue what I was going to ask them at the insurance company.

Band to sleeve revision surgery 1/16/17

HW: 283

CW: 177

GW: 160

[Sosewsue61 3,185]

Usually there is a time frame and rules for the appeal - better find that info out. Also there should be a reason code for denial.

Do a search on Bariatricpal.com for plastic surgery insurance appeals and you may find someone that has had coverage approved after an appeal. There is usually documentation required as a medical necessity ( rashes photo, difficulty performing physical tasks, interfering with daily life, etc) plus all the physicians submitting and surgeons performing the plastics must be approved/in-network and all the reason codes be appropriate.

[jess9395 5,449]

You need to look at your policy too they will often spell specifics out.

For example mine only covers if your pannus hangs 3” past the pubic bone and will only do a breast reduction not a lift and they have to remove a certain amount of tissue for it to me a reduction.

[GassyGurl 428]

Plenty of people appeal, but if you can swing it, check out Lindstrom obesity advocates. They help with appeals. I've not used them, just read about them.

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