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Third-Level / Outside Appeal - Anyone have experience or tips?



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So my abdominoplasty and panniculectomy was approved and covered by my Highmark BCBS insurance, but they denied my brachioplasty (arm lift). I've got tons of medical notes documenting PCP doctor's visits, medications tried for the breakdown and irritation of skin, limitation of movement, my PCP wrote a very convincing letter about why this was a medical necessity and I submitted my surgeon's pictures. I was pretty certain the appeal would be approved. But it wasn't. I was pretty upset. So I'm gearing up to do what the denial letter suggested, and that is to take it to a third level appeal, which would be an outside party evaluating the request.

Has anyone had ANY luck getting appeals approved? What am I missing? What else could I include? Would a letter from my therapist saying it causes me anxiety and depression help? Paying out of pocket with 4 kiddos and 2 of them headed off to college within the next year is just not an option.

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Really wanting to be supportive and certainly wish that you could get everything covered. The world I'm living in is one where we have BCBS but my employer specifically excludes anything to do with bariatric surgery, medical treatment or anything whatsoever. So I have made the commitment to self-pay. Unfortunately, everything in life is not fair and we will not always get what we deserve. But I do believe that we can grow and expand what we are truly grateful for in order to attract more of that into our lives. I would say be grateful that you are getting the panni and Tummy Tuck (most plans just cover the panni without the abdominoplasty). And then look into care credit or some other financing to finance what you need to. Encourage your kids to get part-time summer jobs, and apply for their own student loans if need be. Explain to them that you have earned this and that it is something you need to do to take care of yourself. I am facing similar choices such as I was planning to use the money as a down payment toward my first house. I also have an older car that I would like to upgrade. But life is about choices, and I may have to defer buying a home for another year or two and I may have to just make this car last forever, or at least recognize that there will be one less car over the course of my life. Especially deferring the purchase of my first home is a major life decision, but in the end I think it is worth it to invest in myself and my health.

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What kind of complications do you need to experience before an insurance company would cover an arm lift? I have scars on my left arm from a house fire and I'm still having trouble getting insurance to cover laser. They consider it cosmetic, which drives me mad because its much more than that.

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