Question:
I am almost 1 yr out and about 35 lbs away from goal. I will wait until I am
at goal to even see a plastic surgeon. What does insurance look for in approving surgery on the tummy, inner thighs and "bat wings"? I have BCBS of Alabama with BellSouth. I know they may not pay for the arms, but I am going to give it a try. — Wendy S. (posted on April 19, 2004)
April 19, 2004
Good luck on them paying for the thighs also. Unless they are so huge they
are impeding walking I doubt they will ever pay for them. Bat wings, 99%
of the time are cosmetic so it's real hard to build a case for them also.
I'm not even going to waste my time on those two and I have pretty
significant skin on both, but no rashes/infections or impedment in daily
life, just how they fit in clothes and look naked.
<p>As far as the TT goes it will depend on your particular situation.
While I have never had any rashes, sores or infections under the skin I
had a long history or degenerative disc disease in my low back and tons of
low back pain. I received all kinds of treatment for it from chiro, to PT
to epidurals to living on anti-inflammatories. I got letters from my PS,
WL surgeon, neurosurgeon and orthopedic surgeon. The one that carried the
most weight, no pun intended, was the orthopedic's letter. His letter
proved that it was a mechanical problem that could benefit from the skin
pulling me forward etc. They didn't like the neuro's letter as that was to
iffy as to how it would help.
<p>When we submitted the first time they denied it but indicated they
would review it again, when I was down more weight (we submitted about 80
lbs from goal), with new pictures and an ortho eval and recommendation. We
resubmitted at about 50 lbs from goal. I figured by the time I got an
approval and got scheduled etc. I'd be close to goal. I came out of
surgery 2 lbs under goal. The ortho did a great job and indicated there
was absolutely no question that removing the skin would help relieve stress
in my low back etc. I had approval two days after they had his letter and
new pictures that showed the real me. The picture the PS had submitted
sucked to say the least, so I had my friend take some of me and hand
delivered them to the local office of BCBS along with a letter indicating
my history of back problems. I told them that I realized this would not
cure my back but it was a logical way to manage the condition, just as all
the other treatments I have used and will continue to use. Heck a darn
epidural was almost $1600 last time, so the cost of an abdominoplasty
wasn't so out of line and this should be permanent, not like an epidural.
I can honestly say back issues have been pretty non-existent since I had my
lower body lift 8 weeks ago. They had actually improved quite a bit prior
to PS but are even better now. I do not find myself taking anything for
back pain any more. Knee pain at times but not back.
<p>Look for something specific to build your case on and then get
supporting letters from medical professionals. Don't just rely on the PS
to fight for you. I got my approval because I took charge and got BCBS
what they wanted. If I had left it to the PS I doubt I would have gotten
approval. They talk a good game but won't stick their heads out there and
fight too much. That's my experience with two PS's. The one I got
approval with and the one I eventually had the surgery with. The 2nd one
submitted for approval of the lateral thigh lift, but he didn't include any
details I asked him to which might of helped get it approved and I ran out
of time after my surgery to appeal it. So I had to pay for that portion.
— zoedogcbr
April 19, 2004
Hi Wendy,
Don't set yourself up for failure or frustration regarding thighs and
batwings. I have known BCBS of Alabama to pay for two people's thighs and
one woman's batwings. In all cases there were VERY serious and significant
issues with mobility, hygiene and overall health that impacted their
decision to pay. We have done over 1500 patients in our program and
significantly more than that have come through our support group meeting
and still we've seen BCBS of Alabama cover thighs for only 2 people and
arms for 1. NOW - it's not uncommon to be denied for panniculectomy on 1st
submission. I think they just want us to really work for it. They
generally want to see photos of the apron covering a significant portion of
the pubis. Additionally they want to see evidence of skin conditions or
ortho conditions resulting from the apron. Best wishes to you!
— ronascott
April 19, 2004
One thing to keep in mind is that since we are covered by BellSouth, who
administers the program, our guidelines are a little different from
"standard" BC-BS of Alabama. From what I understand, any
reconstruction is very difficult regardless of the insurance company. I
didn't have a problem with approval for RNY, but I'm not very hopeful on
plastics. Let me know what you experience - I'll do the same. Good luck!
— Debra R.
Click Here to Return