I'm ready for the fight

babsyintx · April 13, 2005

Hi Everyone,

Heres another update about my plastic surgery fight. IT seems that 3 medical directors at SHPS (the precert people for my insurance) got together today and yesterday to discuss my case. They are approving the abdominoplasty, but will not cover the thighplasty. My plastic surgeon called the medical director today for a peer to peer review and tried to convince the director of medical necessity. They are not convinced. THe next step is an external review by a consultant (plastic surgeon).

I personally spoke with the medical director today at SHPS. I thought if I spoke to him myself I might make some headway and not need to go through the external appeal process. He explained why they turned me down. Said the photos and medical documentation from my surgeon did not clearly support the need to have a thighplasty. He didnt think that there was enough evidence that this procedure was medically necessary based on wha he received. He indicated that 3 directors collectively agreed on this decision. Actually, he was pretty nice about everything, although I did not agree with his position in the matter.

We both agreed that they would not submit to the external consultant yet and we would wait a week so I could produce new photos and additional support documentation from my PCP about the infections and some historical data.

I have already given them a letter from my PCP and a letter from my OBGYN. The medical director suggested that I write a letter myself and just have my PCP sign it where I document the dates that I received antibiotics and any other conservative non surgical treatments.

I still have two appeals left. One to the external consultant, another peer to peer review between my plastic surgeon and the consultant and the possibility to appeal directly with Motorola in AZ if this doesnt work. SO worse case scenario is that if I dont win, I can still have the stomach fixed.

So i guess its progress. I will not give up without a fight, but its clear that I wont have firm resolution on this in the next few weeks.

Babs in TX

Alexandra · April 13, 2005

Wow, Babs, you are doing great! I have a good feeling about this--persistence can pay off well in these cases. Good luck, and keep up the fight!!

vinesqueen · April 13, 2005

Excellent start! You know we are pulling for you!

Iluvharleys · April 13, 2005

Keeping my fingers crossed for you! Good work girl!

Mita · April 13, 2005

Seems if they are going to give you more time to submit new photo's and letters that they could be swayed in your direction.. Keeping my fingers crossed for you:)

donali · April 13, 2005

Congrats on being so involved in the process and going after what you want/need. I hope your appeal is approved!!

bandit · April 13, 2005

OHHHHH!!!! Im so glad u kept us updated. I felt so awful for u when I read the post u left the otherday....it was so unfair! Im really happy for u honey!