1st appeal abdominoplasty denied, with hernia repair

[Girlrocker]

My hernia repair with component separation is scheduled for Tuesday, August 19, today is my last day at work before medical leave. I just filed a second appeal. What amazed me about the 1st appeal denial it was like they were responding to someone else entirely. They got the treating surgeon wrong - listed Dr, K. who saw me first, who then recommended I see a specialist, to which there is a doctor's note stating same; denied me because they said I was appealing on the basis of medical necessity and didn't sent documentation,..of a body part I DIDN'T apply for - the pannus (the apron of skin below the belly button). I didn't appeal on medical necessity, I appeal on the basis of reconstruction, there is a statute here in California that distinguishes reconstruction from cosmetic surgery - which is a normal body part for the purpose of enhancement and not physiological benefit. And then? tells me my health care policy only approves reconstruction,...! Same verbiage as in the statute.

I told my surgeon what happened and that I wanted to file a 2nd appeal and again he said he would support me, sign a letter. So I spent the weekend working on a new letter, extracting the portions of the letter where they made mistakes, where I had actually provided the documentation fitting the definition of reconstruction - an upper abdomen severely deformed due to the disease of morbid obesity, the same disease they treated with a bariatric revision, which resulted in multiple hernias and excessive skin, tissue and distention. Pointing out the two procedures they are already doing - hernia repair with component separation - will not restore the deformity to normal physiology and appearance only the abdominoplasty will do that. And by the way the pannus you are referring to was actually removed in 2003 for the same reasons above.

The rest of the history is in this thread link below. I hope this helps others who are looking into this. Paying the difference to have the abdominoplasty is not an option for me ($7k and change), same with the other procedures I would need (lower body lift, rest of my arms, boobs, side boobs, back, thighs). Not to mention that they should fix this, since I have had multiple surgeries already in this same body area. To me it's all part of the same fight for morbidly obese people - what they put people through to have bariatric surgery and then again, with the aftermath. Will keep you posted on result of 2nd appeal.


weightlosssurgery.proboards.com/thread/9269/update-abdominal-reconstruct-approved-appealing

[OnMyWay2Thin]

The whole thing sounds crazy! I hope the letter is received by a rational person who is able to read it properly and approve what you need to have done. Good luck with the appeal and your surgery!

Kelly

[Girlrocker]

It is crazy, and been like a part-time job, couldn't believe that denial letter. So if they are this incompetent, it's a million times worse for people dealing with terminal, catastrophic, life threatening sickness. Thanks for the good words and thoughts, I appreciate it!

[OnMyWay2Thin]

It is hard to believe, isn't it?! I feel as if they don't proofread their own letters, I can't imagine sending out a letter like you describe, wrong body part, wrong wording, then to try and justify their stance by using the wording that would justify the surgery!!! CRAZY... It does become a part-time job and I, also, feel for those with terminal illnesses and life-threatening sicknesses. I'm crossing my fingers for you...

[west4thavenue]

I wish your surgeon's staff could have been more helpful to you. Since the insurance appeal people don't seem to be able to read, perhaps they could hear. (?)

Sharyl, I am hoping and praying and sending every good thought that they will make the appropriate decision this time -- one based upon your appeal.

[bboop]

I'm hoping you get this straightened out. Fingers crossed for you. Damn insurance companies.

[goodkel]

I could probably dig around and look it up, but doesn't CA have some sort of Insurance review board/authority that monitors that insurance is providing the benefits that it is required to deliver?

If so, you might want to cc them, in plain sight, when you send in your second appeal.

[willowrayne]

I think the fact that they obviously didn't consider your request long enough to get the facts straight should be something too.
Arrrggghhh.

"Of all the things I've ever lost, I miss my mind the most."

[Girlrocker]

Thanks all, I really appreciate you being here, the good thoughts, support. Learning as I go through this experience. I know, I have done ALL the work, my doctor's office hasn't done any, but I think unfortunately this is what we have to do, lead the horse to water - seems like a recurring theme in our bariatric process, right? And honestly, probably in the sorry state of healthcare and insurance, still, in this country. So I'm glad that I at least have not one but two surgeons on my side, a lot of help gathering information.

goodkel, didn't know about that board, but I am now multi-tasking as I type and searching for it, thank you again, for pointing this out as you did the California statute and how to appeal. I think this is it? www.insurance.ca.gov/contact-us/0200-file-complaint/

I actually already sent in the second appeal, damnit, I spent last weekend working on the 2nd letter, putting the exhibits together; I did cc Dr. Keshishian so that it reflects his blessing as well, besides his actual doctor note they managed to overlook. I have a pre-op appointment today, so I'm hoping to find this board, and get a number, so I can have the insurance 'coordinator' call insurance to check on the status of the appeal TODAY, tell them of this board, I will script her what to say. And I'm writing my surgeon now to tell him I'll need just this one call, insurance needs to hear from the doctor's office at least once, I think(!!!) so she knows its ok.

[mlleelise]

Sharyl,
So sorry that you're having to deal with this headache! I've about given up on insurance companies. They really do not exist to help their clients - only to make an Almighty Buck. I've appealed too many times to remember...and never have won. I sure hope that Dr. Keshishian's letter will help, along with all of your documentation. You certainly deserve it!
PS I sent you a personal message :-)

[goodkel]

goodkel, didn't know about that board, but I am now multi-tasking as I type and searching for it, thank you again, for pointing this out as you did the California statute and how to appeal. I think this is it? www.insurance.ca.gov/contact-us/0200-file-complaint/

Yes! That is exactly what I was thinking of.

[west4thavenue]

Aug 15, 2014 9:19:17 GMT -5 Girlrocker said:

goodkel, didn't know about that board, but I am now multi-tasking as I type and searching for it, thank you again, for pointing this out as you did the California statute and how to appeal. I think this is it? www.insurance.ca.gov/contact-us/0200-file-complaint/

I actually already sent in the second appeal, damnit, I spent last weekend working on the 2nd letter, putting the exhibits together; I did cc Dr. Keshishian so that it reflects his blessing as well, besides his actual doctor note they managed to overlook. I have a pre-op appointment today, so I'm hoping to find this board, and get a number, so I can have the insurance 'coordinator' call insurance to check on the status of the appeal TODAY, tell them of this board, I will script her what to say. And I'm writing my surgeon now to tell him I'll need just this one call, insurance needs to hear from the doctor's office at least once, I think(!!!) so she knows its ok.

Good luck, Sharyl.  Maybe just knowing you are contacting the State about your appeal will prompt your insurance company to read more carefully and do the right thing.  I hope I hope I hope I hope!!!!!

[Girlrocker]

It has been a nightmare, bold face sleazy lying. Im definitely reporting them firche mistakes and lies.

Sent by the semi-smart phone

[mistercy]

Shaking critters for ya today on surgery day, Sharyl! May it all go well! Hopefully, all the insurance stuff worked itself out, too!

[MsVee]

Praying all goes well!



MsVee

[Leonie]

Sharyl, you must be out of surgery by now. Please let us know as soon as you are able. Until then, know that we are rooting for you. Now, breathe, hold still and enjoy those pain meds.

[illinids2]

Hope everything went well and you are on a comfortable path to quick healing.

[newyorkbitch]

Thinking of you!

[ttfulmer]

Praying

[goodkel]

I hope all is well.