pre-emptive file building
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Im looking to get a TT around August ( gotta build back FMLA hours since I stayed out a LONG time after VSG surgery) .... so Im thinking Im a lil late on starting to build a file that will encourage Aetna to pay for it....
So far Im down 70 pounds ( not quite 5 months post-op) with another 70 to go....Im thinking about getting TT at about 160 pounds which is about 45 pounds away....that will make me about 115 lbs down....
So my major questions are, What "ailments" do I need to be suffering from to get insurance approval or partial approval? rashes, etc... Do I need to see dermatologist?? PCP... will my own pics of these rashes suffice?? How much of a history of rashes and any other ailments do I need?
Is it possible to get insurance to pay for ventral hernia repair ( I was told I had hernia years ago) , panni and then I pay for the rest?
http://www.aetna.com/cpb/medical/data/1_99/0031.html
The following procedures are considered medically necessary when criteria are met. The requesting physicians may be required to submit documentation, including photographs, letters documenting medical necessity, chart records, etc.
Panniculectomy: Considered medically necessary when criteria are met, as set forth in CPB 0211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair.
Ventral hernia repair: Considered medically necessary when criteria are met, as set forth in CPB 0211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair.
http://www.aetna.com/cpb/medical/data/200_299/0211.html
Aetna considers panniculectomy/apronectomy medically necessary according to the following criteria:
The medical records document that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 3 months while receiving appropriate medical therapy (e.g., oral or topical prescription medication), or remains refractory to appropriate medical therapy over a period of 3 months.
Aetna considers panniculectomy/apronectomy cosmetic when these criteria are not met.
Aetna considers panniculectomy/apronectomy experimental and investigational for minimizing the risk of hernia formation or recurrence. There is inadequate evidence that pannus contributes to hernia formation. The primary cause of hernia formation is an abdominal wall defect or weakness, not a pulling effect from a large or redundant pannus. [*]
Aetna considers repair of a true incisional or ventral hernia medically necessary.
[*]Aetna considers repair of a diastasis recti, defined as a thinning out of the anterior abdominal wall fascia, not medically necessary because, according to the clinical literature, it does not represent a "true" hernia and is of no clinical significance.
[*]
Aetna considers abdominoplasty, suction lipectomy, or lipoabdominoplasty cosmetic.
Background
In order to distinguish a ventral hernia repair from a purely cosmetic abdominoplasty, Aetna requires documentation of the size of the hernia, whether the ventral hernia is reducible, whether the hernia is accompanied by pain or other symptoms, the extent of diastasis (separation) of rectus abdominus muscles, whether there is a defect (as opposed to mere thinning) of the abdominal fascia, and office notes indicating the presence and size of the fascial defect.
Abdominoplasty, known more commonly as a "tummy tuck," is a surgical procedure to remove excess skin and fat from the middle and lower abdomen and to tighten the muscles of the abdominal wall. The procedure can improve cosmesis by reducing the protrusion of the abdomen. However, abdominoplasty is considered by Aetna to be cosmetic because it is not associated with functional improvements.