I am sad and angry...

[babsyintx 0]

Hi Everyone,

An update on my plastic surgery saga. I was approved by my insurance company for an abdominoplasty which was originally scheduled for May 5th 2005. I decided to change plastic surgeons and went for a new consult a few weeks ago. The new surgeon was willing to do multiple procedures at the same time. Originally I wanted to have a medial thighplasty and TT at the same time, but the first surgeon (who works alone) did not want to do this. Surgeon 2 has no problems with this because he tag teams with a partner and they work together and are able to complete the surgery in half the time this way. I figured it was better to have both surgeries done together so I would only have to be in pain and recover one time. I was also going to pay to have a breast augmentation with implants and then I would never have to go back and have additional surgeries.

The new surgeon submitted photos and letters from my PCP, OBGYN and clinical notes on why I need a medial thigh lift. He also resubmitted documentation and photos for the abdominoplasty since although there was already a previous approval, it was now a new surgeon and a new surgery date of June 15th.

I am devastated. I was turned down for the original approval for the TT and they also turned down the thighplasty. They turned down everything! I asked how this could happen, since I was assured that my previous approval could not be turned down for the abdominoplasty just because I changed surgeons. Apparently a diifferent medical director looked at the case and decided I no longer needed an abdominoplasty and the thigh were a no no as well. My case manager is in the process of finding out if we can use the previous authorization for the one surgeon and switch it to another for the abdominoplasty. I will have to go through the appeals process now for the thighs. This consists of a peer to peer review between my doctor and the medical director.

I am both angry and really sad. I have been crying for the last hour. I have hope that this will resolve itself. I am hoping at the very least that the TT will be approved (since it was already with dr. #1) but I really dont have the money to pay for a thighplasty and the problems with my thighs are worse than any other body area. I was planning on paying for the breast augmentation. I dont understand how they can approve a procedure several weeks ago and turn it down a few weeks later. Does this make any sense? Its humiliating enough to know that some dumb director is looking at pic of my hanging stomach, saggy thighs and deflated boobs and assessing medical necessity. THe case manager read the notes to me from the medical director and he adds insult to misery by saying although my thigh are large, he doesnt see how a thighplasty will help me. My plastic surgeon says that he needs to remove at least 4 pounds from each thigh. How can a medical director think that removing this excess skin which has a lot of breakdown already not be medically necessary?

I am depressed....

[Penni60 45]

AWWW babs: want me to kick that medical director's ass? What a complete and insensitive sot. I think these people just sit there and look at pics and reports and close their eyes and point a finger at a file and say ok that one gets the surgery the rest are denied. I agree how can they make a call like that? I don't get it.

IF you were approved once for the first surgery and surgeon why would they now deny it? Hmmm! Is there a suit in the making?

Babs it will get better. IT WILL!! I will keep you in my prayers.

[babsyintx 0]

Hi Penni,

You have my permission to hurt him. But lets wait until after the peer to peer review. If he doesnt approve the thighplasty, I will personally kick his ass. The wrath of Babs! Sounds like a movie. I am trying to keep my chin up. I have credit card and will travel to some other country and have it done, so not all is lost. It could be worse.....

Babs the Invincible Bitch who is hell on wheels when someone gets on my band side.....

[vinesqueen 2]

((((((((((Oh Babs! ))))))))))

I am so sorry you got this news.

Yeah, "medically neccessary" is quite the quandry, especially when viagra, et. al, get approved, but birth control is another matter entirely....

It took a long time to get my second skin graph after my motorcycle accident. I cannot tell you the number of Dr.s who said I just needed to baby the original site. Baby it hell! I had to sleep with a wet cloth on my leg just to help control the uncontrolable itching. In warm weather I would have to spend all day with my leg elevated to held reduce the seepage. And they kept telling me that I just needed to baby it an to quit whining about it. The insureance company kept turning the revision down bacause it wasn't "necessary."

Fight this Bab! Fight! Fight! Fight! You know that we are all here for you. We all send you such wave of positive energy, we remember you in our prayers, no matter whom we pray to. If you need help with your letters, I know we have some very eloquent writers here who would jump at the chance to help you.

You said the skin on your thighs is breaking down, are you bleeding? I should think at the very least you are suseptable to skin infections similar to celulitus. You might think about that angle when you write your letters.

(((((((((( Babs! ))))))))))

[Penni60 45]

I gotcha ya back!!

Hi Penni,

You have my permission to hurt him. But lets wait until after the peer to peer review. If he doesnt approve the thighplasty, I will personally kick his ass. The wrath of Babs! Sounds like a movie. I am trying to keep my chin up. I have credit card and will travel to some other country and have it done, so not all is lost. It could be worse.....

Babs the Invincible Bitch who is hell on wheels when someone gets on my band side.....

[MeganA 35]

Go to the mattresses, Babs! Don't take this crap. I am sorry you're so disappointed.

Megan

[DeLarla 22]

I'm with Megan on the mattresses! The squeaky wheel gets the oil. I read this earlier but was too disgusted with the whole thing to answer. How can you get a girl's hopes up like that just to smash them down? My belly is sick over it.

[dylansmom 27]

How horrible of them! I sure hope that when you fight this you'll win! Insurance companies can be such dirty ol buggers!

[babsyintx 0]

HI Guys,

I started with the hounding already. Called this evening to follow up with the discussion I had with the case manager earlier today. Apparently, they did take my case back to the medical director during the day. He spoke with the first medical director that reviewed the case and they agreed to honor the previous approval for the abdminoplasty. SO yeah!!!! It must have been the threats that I would sue them for backing out of the previous approval that got them off their butts...

It is not clear what they will do about the thighs yet. I will know more tomorrow. So the good news is that the previous approval prevails for the stomach!!! OK, we are halfway there.... Probably will still have to do peer to peer review (which is considered second appeal) on the thighs though. I'll let you know tomorrow!!!!

Babs in TX

[La_madam 20]

Good News Babs, that is great. I hope you get the same good news tomorrow about the thighs!

[dylansmom 27]

Congratulations! How exciting!!! Crossing my fingers for approval on the thighs for you too!

[shamrock 0]

Insurance companies AGH! I wonder sometime of they even look at the paper work or just stamp them yes, yes, no. yes, yes no. Good luck on the thight job I'm rootiing for you.

[chatt.earthmom 0]

You stay with them girl. I have been an insurance care manager in behavioral health and even though they don't tell you you can't approve something (unless the policy has an exclusion or statement of noncoverage) they expect you to work your hardest to keep the patient from getting anything expensive, but if you go through all the channels and don't give up, you can win in most areas. If you don't get it approved, get a good attorny involved and make sure you have continuous documentation of skin break downs occuring subsequent to denial.

[Jammin & Losin 1]

Babs I'm so glad that something is starting to get better with all of this. I sure hope you will be able to get all that you are trying to get approved for!!! GOOD LUCK!!!!

[Banded14yr 2]

Babs!

Stick to your guns! Way to go! I'm keeping my fingers crossed that EVERYTHING will work out for you! Keep us posted.