Hi Everyone,

An update on my plastic surgery saga. I was approved by my insurance company for an abdominoplasty which was originally scheduled for May 5th 2005. I decided to change plastic surgeons and went for a new consult a few weeks ago. The new surgeon was willing to do multiple procedures at the same time. Originally I wanted to have a medial thighplasty and TT at the same time, but the first surgeon (who works alone) did not want to do this. Surgeon 2 has no problems with this because he tag teams with a partner and they work together and are able to complete the surgery in half the time this way. I figured it was better to have both surgeries done together so I would only have to be in pain and recover one time. I was also going to pay to have a breast augmentation with implants and then I would never have to go back and have additional surgeries.

The new surgeon submitted photos and letters from my PCP, OBGYN and clinical notes on why I need a medial thigh lift. He also resubmitted documentation and photos for the abdominoplasty since although there was already a previous approval, it was now a new surgeon and a new surgery date of June 15th.

I am devastated. I was turned down for the original approval for the TT and they also turned down the thighplasty. They turned down everything! I asked how this could happen, since I was assured that my previous approval could not be turned down for the abdominoplasty just because I changed surgeons. Apparently a diifferent medical director looked at the case and decided I no longer needed an abdominoplasty and the thigh were a no no as well. My case manager is in the process of finding out if we can use the previous authorization for the one surgeon and switch it to another for the abdominoplasty. I will have to go through the appeals process now for the thighs. This consists of a peer to peer review between my doctor and the medical director.

I am both angry and really sad. I have been crying for the last hour. I have hope that this will resolve itself. I am hoping at the very least that the TT will be approved (since it was already with dr. #1) but I really dont have the money to pay for a thighplasty and the problems with my thighs are worse than any other body area. I was planning on paying for the breast augmentation. I dont understand how they can approve a procedure several weeks ago and turn it down a few weeks later. Does this make any sense? Its humiliating enough to know that some dumb director is looking at pic of my hanging stomach, saggy thighs and deflated boobs and assessing medical necessity. THe case manager read the notes to me from the medical director and he adds insult to misery by saying although my thigh are large, he doesnt see how a thighplasty will help me. My plastic surgeon says that he needs to remove at least 4 pounds from each thigh. How can a medical director think that removing this excess skin which has a lot of breakdown already not be medically necessary?

I am depressed....

Keeping my fingers crossed for you!

what crap news Babs, hope you fight it AND WIN! By the way, I hear great things from people in the UK and here in Ireland, that South Africa is pretty good value for plastic surgery....there are resorts where you come back to after the surgery and rest for two weeks....just a thought - really hope it works out for you xx

I heard that you can submit a bid for approval again you might have to document consequences such as rashes, chafing , yeast infections you have to keep fighting the sqeaky wheel gets what they want.

... they agreed to honor the previous approval for the abdminoplasty. SO yeah!!!! It must have been the threats that I would sue them for backing out of the previous approval that got them off their butts...

Well, at least you've had some good news. Now let's hope they go for the thighplasty, otherwise it's ass-kickin' time.

Hi Zoe,

Like the boot.

I'm hanging in there. I am getting all my ducks in a row and will fight tooth and nail. I am still optimistic. Hey, at least I can get the TT.....

Babs in TX

Oh my word!!!! What state & insurance company do you have . . . I want to make sure I NEVER use them. Why is it that they are even in this business; must it always be anti-patient and pro-holding our money. Babs, please know that I am praying for you and hoping it all get's turned around for your good very quickly. It is a shame for sure and I am very sorry this has happen to you. You have done so well in lossing so much weight; please, don't let this get you down. It's just a crazy world.

Always,

Judy

Hi Judy,

I actually have really good insurance. They paid for my lapband and made a decision in one day! They are paying for my tummy tuck, but did not feel that the pics and clinical data was adequate to approve the thighplasty. I am appealing and still have two appeals left. Hopefully, I wont have to use them all. Not many insurance companies want to pay for thighs. Most of them dont want to pay for anything. I think statistically only 40% of people who get the lapband actually get their insurance companies to pay for it. I am here in TX and have the Motorola Rewards PPO administered by Humana Choicecare. Things used to be easier when CCN was the network provider. They do pay for my fills (I have had 7 and they paid for my band, so I cant squawk too much. IT is disappointing to be turned down, but I think with an appeal, I should be able to win this. We shall see.....

Babs in TX

Dear Babs,

I LOVE that spirit and I do so hope they will quickly come through for you. Please keep us posted and know that we all care. You are such a special person and a true lap-band sucess and roll model.

Always,

Judy

Way to be presistant Babs!!!!!! I am very happy they decided to honour their first ok on the TT & I pray that your thigh lift will go through as well. I will keep you in my prayers. I never had any idea how long a prayer list could be until I joined LBT:0)

I hate the fact that strangers can determine what makes us comfortable in our own lives. Who is anyone to say if someones thighs will be better lifted or not? Only the person dealing with the problem can truely say how it effects them.

I wish if they weren't going to cover the surgeries they would just not cover any surgeries. It ticks me off when I find out one person can qualify and another can't.