what constitutes "medical necessity"?

[J-squared 0]

Hey All;

I am 3 years post lap-band surgery. I've lost 80-85 pounds to date. I am so close to goal I can almost taste it.

I have a question in regards to plastic surgery and those who have had success with getting their insurance to cover it. My insurance will cover it if it's medically necessary.

I have issues with my knees (already have had 3 knee surgeries) and shoulders, and in my opinion having the extra skin hanging off my arms and thighs isn't helping.

Also, I have a large flap of skin overhang on my lower abdomen.

I've reached a point where I don't think much more weight is going to come off until I get rid of this skin, and gain some more movement.

What are your thoughts - facts, things you have found useful in getting insurance approval?

And where should I start the process - with my Lap-Band doctor, or go to a plastic surgeon for a consult, first?

Thanks!

[Cindy C 150]

I doubt you will be able to get the insurance to approve the legs or arms. They might be willing to do the Tummy Tuck if you can prove that you are getting yeast infections under the loose skin. Have your doctor prescribe Nystatin cream or powder. The prescription will serve as documentation whether you use it or not!

[khath0620 20]

I am down like 85'ish and i have the belly thing too. I do have a paper trail of pharmacy orders, doctor's notes (both from my PCP and dermatologist) and photo documentation. I am about 15 punds away from my goal and need to start the process of finding a plastic surgeon who has dealt with LB patients. I really NEED a full body lift but I am fairly certain that insurance will not cover that. Guess it is worth a try though....

Good luck,

Katie

[ShrinkingLizzee 0]

ive been told by my family doctor that depending how much skin is stretched and is sagging i the arms that someways it can be covered due to that its restrictions,

for example

over here in ontario we have ohip , and my family doctor said because my arms are so stretched out they are very heavy now so its now making daily life activites unable to do my byself or without causeing alot of strain and pain

hope that helps

[Matt Z 4,140]

You first step should be to contact your insurance company and get the list of approved and expempt surgeries. For my current insurance, all I need is to have a flap caused rash, sores or infections of some sort to qualify for the abdominal region. As far as everywhere else, that's a much different story.

Your steps to this process should be as follows.

1. Find out if your insurance covers it and under what conditions. No sence getting your primary or your WLS involved if your insurance has it exempt for all reasons.

2. If your insurance company does have conditions that garner approval, check to see if they are what you are experiencing, if it's sores and the such and you say "well I have mobility issues" they will point back to the coverage documents and tell you goodbye.

3. If you do have a condition that is listed as an approved reason for plastic/cosmetic surgery, contact whomever has been treating these issues, have them fax all the information to you so you have a copy as well. If this person is your primary, next would be to contact your WLS and inquire about plastic/cosmetic surgeons that they have referred patients too. Some medical insurance requires referral from either your primary, your WLS or both.

4. Depending on method required by insurance, you will either contact the plastic/cosmetic surgeon yourself to set up consultations and the plastic/cosmetic surgeon will file the insurance claim. Or your Primary or WLS will file the claim prior to you seeing the plastic/cosmetic surgeon.

That's pretty much it, hope that helps you out some! It's a right pain the butt with each and every company working in different directions to get something done!