allycatt98

Theard,
I was a Pre-Auth Nurse so I will share what I know about the process.
1. Some offices try to flood you with paper (labs, office notes, imaging, etc.) -- it's annoying and it doesn't help the patient's chances for approval. I couldn't stand it. Seriously, 100 pages! How about giving me the info I need to make a decision?
2. Missing/Incomplete documentation: All the required documentation must be submitted. If five years of documented weight loss is required, then that's what the nurse is looking for. If there is a nutritional counseling requirement, then the nurse is looking for complete records from the practitioner that include diet, exercise, etc. You'd be amazed how many people miss this one. The NUT and Psych documentation must include all the elements required by the insurance company. Many of the commercial plans have templates available that you can give to your practitioner.
3. Medical Necessity isn't met: This one is a biggie and will often cause an immediate denial. Those letters of medical necessity that the docs send in are often a waste of time and are usually only useful at the time of an appeal. If criteria isn't met, then your Doc needs to be prepared to discuss the reasons why you need the surgery with the health plan's Medical Director. They can call in while the case is being reviewed or do a peer-to-peer review after it is denied. Basically, the doc has to care enough to prove your case. Some do, some don't.
Hope this helps. Let me know if you have any questions.
P.S. The 30 day timeframes a quoted are BS.
Medicare: 14 calendar days for standard (non-emergent) requests with an additional 14 calendar days if an extension is granted because it is in the best interest of the enrollee; i.e. additional time to submit required documentation or have tests done to meet criteria. The health plan is required to advise you in writing if an extension is needed AND you have the right to file a grievance if you disagree.
Medicaid: every state is different (i.e., New York and Missouri require a three business day TAT. But if additional info is needed the NY cases are allowed to go up to 14 calendar days). The default for all Medicaid states is typically 14 calendar days. Some states require an even shorter TAT as mentioned. Even if an extension is granted it is typically only for up to 14 calendar days.
NCQA accredited health plans: If the TAT criteria listed above does not apply (i.e. Commercial Health Insurance) then check the plan's accreditation. NCQA requires a no more than 15 calendar day TAT with an additional 14/15 calendar days if an extension is granted. However, you still have to be notified in writing than the Health Plan granted an extension AND the notice should specify why it's being granted.
I know I typed a lot. Hopefully it helps. Sorry for any typos, I'm on my iPad.
Ally.

Hi Goddess,
I'm in Tampa, but just had a consult at USF Health. They offer a 50% discount at their Resident Plastic Surgery clinic and since they are quite familiar with the insurance process. If you're in south Florida, I would inquire about the University of Miami plastic surgery clinic if you discover that the insurance option isn't feasible. I've dealt with them in the past, and they are well versed with insurance payors.
I would say that most docs, (if they're affiliated with your insurance plan) are familiar with the Prior Authorization guidelines. The best advice is for you to review, review, review your benefit plan. Some of them have a dollar limit max on procedures related to the weight loss including post-op plastics.
This is such an exciting process. I'm still not sure of my next steps....... Best wishes to you!
Ally

Hi Amazon,
I had a consult with Dr. Sauceda a few weeks ago. I found him to be very pleasant, but was extremely surprised that he seemed unfamiliar with Von Willebrands... even the recommended treatment during surgery. In comparison, I had a totally unplanned phone consult with Dr. Carmena Cardenas last Saturday and she was well versed and familiar with the treatments. Additionally, he made it a point to tell me how African American skin keloids, has poor scar healing, etc. Kind of like he was setting me up for disappointment....

Agreed! OMG that someone (with a phone and a CPA no less) would want tax advice from random internet posters instead of the IRS.

I thought my response was clear and relevant to the post, but okay. Not everyone interprets things the same way. So I will rephrase this.....
We have the ability to apply any of the available deductions when we submit our taxes. It's only if and when we are audited, that your questions would actually become relevant. There could be hundreds (or thousands) of people out there that have applied this deduction. Only the ones that were selected for an audit can honestly tell you if the IRS accepted/allowed this deduction after a manual review.
That being said, the results will still vary by individual because there is a medical necessity requirement. Perhaps this is just clear to me because I have experience developing evidence-based criteria.
IRS language pasted from your reply:
necessary to improve a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease."
Notice the key word "necessary." Based upon your health history, can you prove that the removal of the excess tissue was necessary to improve a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease? Is your excess skin (as a result of obesity) so extensive or impairing that it could be considered a disfigurement?
Based upon the language you were kind enough to paste in your reply, my previous reply is still appropriate. Honestly, this would be easily remedied by just contacting the IRS and asking about the audit process related to medical deductions: "What type of documentation is required if I'm audited? Do you need documentation from my physician to support my use/application of this medical deduction?"
You would probably be better off obtaining this information directly from the IRS (regarding their specific requirements) instead of relying on someone else's results (that are based upon their own personal health history).
I hope you're able to get the information you need in order to move forward.
JerseyCityGal,
I understand your question, but everyone's situation is different.
Let's say you took a deduction in 2014 for your Sleeve and were audited, would you be able to prove that it was medically necessary? That's really the issue here. You could definitely attempt to take the deduction. I've done it for dental work that was considered cosmetic. But if I were audited, I have the documentation to prove that my dental work was medically necessary even if it wasn't covered by my insurance.
I don't think one answer fits all situations.... It's not the same as an itemization for home office expenses (it would be so much easier if it was ). It gets really murky when you start comparing medical procedures and services. My sleeve was approved by the insurance company on the first submission within 48 hours, but there are tons of people on the board that have been repeatedly denied by their insurance company. I think this one is going to be dependent on the documentation that you have to support your deduction in the event of an audit.
I know that's not the answer you were looking for but it's the truth and audits are evil.
Ally
No offense, seriously, but you are not getting it..
If you have an official medical diagnosis of Obesity, yes, your VSG is deductible (% of AGI and all that). If you had it done for shits and giggles and were not obese, it won't work.
"Medically necessary" does not appear in the Cosmetic section of the tax code. What does appear is " if it is necessary to improve a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease." It does not seem to me that Obesity falls under any of those categories, but I did find one US tax court case that allowed a woman with an over 100 lb weight loss whose abdominal skin got in the way of her movement for her job to take the deduction.
I am SPECIFICALLY asking:
1) people who have had reconstructive types of plastic surgery after massive (over 100 lb) weight loss; i.e. skin removal/LBL, arm lifts, etc (not a tiny Tummy Tuck but major surgery)
2) Did you claim these surgeries as a deduction on your tax returns?
3) How did it work out for you? Was it questioned?

Agreed! OMG that someone (with a phone and a CPA no less) would want tax advice from random internet posters instead of the IRS.

Rude

@@JerseyCityGal no offense, seriously, but you are acting like an ass. Give it a rest already.

Ouch. She's a CPA and took the time to answer your post. Is it necessary to blast people who are trying to be helpful?It seems like you are looking for a specific answer. I'm sure if you search long and hard enough you will find all sorts of people claiming and deducting things on their taxes that wouldn't fly if they were audited. In my opinion, the plastic surgery your are speaking of doesn't qualify as a deduction. How about you claim it on you taxes and report back to us if you got audited? I will probably pass as I've already been audited once in my lifetime by the IRS. I prefer to stay under the radar ????

I thought my response was clear and relevant to the post, but okay. Not everyone interprets things the same way. So I will rephrase this.....
We have the ability to apply any of the available deductions when we submit our taxes. It's only if and when we are audited, that your questions would actually become relevant. There could be hundreds (or thousands) of people out there that have applied this deduction. Only the ones that were selected for an audit can honestly tell you if the IRS accepted/allowed this deduction after a manual review.
That being said, the results will still vary by individual because there is a medical necessity requirement. Perhaps this is just clear to me because I have experience developing evidence-based criteria.
IRS language pasted from your reply:
necessary to improve a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease."
Notice the key word "necessary." Based upon your health history, can you prove that the removal of the excess tissue was necessary to improve a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease? Is your excess skin (as a result of obesity) so extensive or impairing that it could be considered a disfigurement?
Based upon the language you were kind enough to paste in your reply, my previous reply is still appropriate. Honestly, this would be easily remedied by just contacting the IRS and asking about the audit process related to medical deductions: "What type of documentation is required if I'm audited? Do you need documentation from my physician to support my use/application of this medical deduction?"
You would probably be better off obtaining this information directly from the IRS (regarding their specific requirements) instead of relying on someone else's results (that are based upon their own personal health history).
I hope you're able to get the information you need in order to move forward.
JerseyCityGal,
I understand your question, but everyone's situation is different.
Let's say you took a deduction in 2014 for your Sleeve and were audited, would you be able to prove that it was medically necessary? That's really the issue here. You could definitely attempt to take the deduction. I've done it for dental work that was considered cosmetic. But if I were audited, I have the documentation to prove that my dental work was medically necessary even if it wasn't covered by my insurance.
I don't think one answer fits all situations.... It's not the same as an itemization for home office expenses (it would be so much easier if it was ). It gets really murky when you start comparing medical procedures and services. My sleeve was approved by the insurance company on the first submission within 48 hours, but there are tons of people on the board that have been repeatedly denied by their insurance company. I think this one is going to be dependent on the documentation that you have to support your deduction in the event of an audit.
I know that's not the answer you were looking for but it's the truth and audits are evil.
Ally
No offense, seriously, but you are not getting it..
If you have an official medical diagnosis of Obesity, yes, your VSG is deductible (% of AGI and all that). If you had it done for shits and giggles and were not obese, it won't work.
"Medically necessary" does not appear in the Cosmetic section of the tax code. What does appear is " if it is necessary to improve a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease." It does not seem to me that Obesity falls under any of those categories, but I did find one US tax court case that allowed a woman with an over 100 lb weight loss whose abdominal skin got in the way of her movement for her job to take the deduction.
I am SPECIFICALLY asking:
1) people who have had reconstructive types of plastic surgery after massive (over 100 lb) weight loss; i.e. skin removal/LBL, arm lifts, etc (not a tiny Tummy Tuck but major surgery)
2) Did you claim these surgeries as a deduction on your tax returns?
3) How did it work out for you? Was it questioned?

DaddyMarie,
Sorry, I didn't mean to imply that it wasn't a valid question. It's just usually the question is a result of misconceptions about healthcare in the States.
There is a difference between the care people receive in state run (or public) facilities vs. private for-profit institutions wherever you go. So when we talk about Mexico, the Carribean or wherever, we aren't necessarily referring to the same institutions that are utilized by the residents of the area. The facilities that people are going to cater to tourists. This is how they make their money. These wouldn't necessarily be the same facilities that make the indigenous women give birth on the front lawn.
There are definitely some horror stories about Mexico. But there are some facilities here that you couldn't pay me to visit. The difference is that while I wouldn't be able to afford a private facility here, I could afford one in MX.
The typical MX patient is someone that either does not have coverage for their medical procedure or their insurance costs make it unattainable. The MX option allows for affordable, quality, customized healthcare. Most people wouldn't be able to afford that option here and wouldn't get the perks offered in MX.
Does that make sense?
Ally

I'm sure GreenEye will have her own response, but why is there such an assumption that seeking medical care abroad is such a risk? If you do your research, you'll discover that the US does not have the best health care model. Even worse, the health care costs here are ridiculously high. So why wouldn't people seek quality affordable healthcare elsewhere?
For every horror story about Mexico, there are probably ten times that for care in the States. Medical Tourism is big bucks and these providers are doing their best to attract and keep clientele.

I'm sure GreenEye will have her own response, but why is there such an assumption that seeking medical care abroad is such a risk? If you do your research, you'll discover that the US does not have the best health care model. Even worse, the health care costs here are ridiculously high. So why wouldn't people seek quality affordable healthcare elsewhere?
For every horror story about Mexico, there are probably ten times that for care in the States. Medical Tourism is big bucks and these providers are doing their best to attract and keep clientele.

meat, especially chicken was a problem for me at first. I'm glad to have made it thru the awkward stage. Now I'm struggling with fluids. When I'm on the road it's hard to get them down because my stomach is a social butterfly.... sing, sing, sing. Then my nutritionist says I need 90 grams of Protein a day! And this is going to happen how? I'll be honest, they're more days than I'm proud to admit that I only get in a liter of fluids. I'm pushing myself to get better, but it's easier said done. Heck I'm just happy to still have hair.

Having the surgery was the best decision I've made in years. My surgery was on July 10th and I'm tolerating all textures with no dumping issues. I'm so blessed. The biggest problem for me is that my stomach likes to "sing" sometimes when I'm drinking fluids. Not a problem when I'm alone, but in a client meeting, it presents a problem.

Having the surgery was the best decision I've made in years. My surgery was on July 10th and I'm tolerating all textures with no dumping issues. I'm so blessed. The biggest problem for me is that my stomach likes to "sing" sometimes when I'm drinking fluids. Not a problem when I'm alone, but in a client meeting, it presents a problem.

Having the surgery was the best decision I've made in years. My surgery was on July 10th and I'm tolerating all textures with no dumping issues. I'm so blessed. The biggest problem for me is that my stomach likes to "sing" sometimes when I'm drinking fluids. Not a problem when I'm alone, but in a client meeting, it presents a problem.

I would use my HSA debit card preferably.

Hi Rella,
Your should be able to use HSA funds for the surgery in addition to claiming the expenses above and beyond HSA on your taxes. I would prepare a packet similar to what would be submitted for regular insurance approval: BMI, history of weight loss attempts, nutritional counseling and any documentation you've received from the surgeon. I've also used FSA funds in the past for physician directed weight loss programs.
I hope this helps.

Hi Rella,
Your should be able to use HSA funds for the surgery in addition to claiming the expenses above and beyond HSA on your taxes. I would prepare a packet similar to what would be submitted for regular insurance approval: BMI, history of weight loss attempts, nutritional counseling and any documentation you've received from the surgeon. I've also used FSA funds in the past for physician directed weight loss programs.
I hope this helps.

No advice bc my date is also 7/10. Im on day nine of my liquid diet. I moaned about donuts on the phone with my mom today. But the finish line is in sight. Then we begin a totally new battle.
Looking forward to seeing you on the finish line Soto!

I agree! I ordered 4 of their sample packets: Birthday Cake (blech!), strawberry (good), vanilla (okay) and banana (really tasty). The best part was that the balance of Stevia was perfect and I didn't need to add anything else. I buy mine off of Amazon because it's much less than buying directly from SDC.

I don't plan on ever dying at all, but assuming I have to at some point, I decided I would rather risk going out on the operating table while trying to improve my life than inevitably wasting away from being morbidly obese.
(PS: I think I've read that you have a higher probability of dying from a hip or knee replacement than you do from gastric sleeve.)

I can see why! I'm so impressed and inspired. How long did it take you to achieve this?
Ally

I have UHC with the Optum Bariatric Resources Program. So my physician/hospital choices are extremely limited. There are approximately ten hospitals in my area, but I can only use one of them per the plan and I'm not going to Tampa General. I can do better for a $3000 deductible.
Other than that, my requirements aren't bad: 6 months of nutritional counseling and a psych eval. I go for my third visit on Thursday. So I'm projecting a July surgery date. Nutritional counseling of course isn't covered by the plan, so I opted to use the RD sessions offered at Florida Hospital's Wellness Center -- 6 sessions for $250.
Next, I have to go see my Hema/Onc to develop a strategy for surgery bc of my bleeding disorder and then take care of the psych eval. I'm scheduled to go back to my surgeon for the pre-op right after my last NUT visit late June. I'm anticipating a three business day turn-around for the approval.
Ally