Question:
EMERGENCY HELP needed on TT appeal, please!!
Quick background... I had surgery almost 11 months ago and have lost 155, but still have 90 to go. For the past 5 months, I've been essentially stuck. NOTHING makes a difference. After much discussion with my PCP, surgeon, nutritionist, and psychologist, everyone agrees that my "answer" at this point is to have a panni because so much of my weight is in my stomach. The plastic surgeon agrees that it would be be extremely beneficial even though I'm not at goal. He says I may need/want to do it again then, but to get there, I need to do this now. I have a HUGE apron, hanging down on my legs, sloshing around when I lay in bad, it's gross! He says having it done now will reset my metabolism and another patient of his who had it done like this went on to lose 75 more pounds fairly quickly. Anyway, CIGNA doesn't think it's necessary, citing no documented history and it's not a pysical limitation (hahahahahaha!! - they even had pictures!) All previously mentioned specialists are willing to write letters for the appeals process, but I am hoping for some tips on what they should include. Especially from my psychologist, he has specifically asked me for what type of information I hope he'll say. ANY tips would be greatly appreciated!!! THANK YOU!!!!!!!!! — jen41766 (posted on June 23, 2003)
June 23, 2003
I am kinda in the same situation. Have lost over 200 pounds but the last
few months my weight loss is really slowed. All the weight I need to lose
is in my legs. My PCP and PS agreed that without my apron, I could
concentrate on my legs and better able to exercise. I was denied on the
PS's preauthorization letter. I have sent my appeal, on the angle that this
is not cosmetic surgery but reconstructive surgery. If you want to see the
letter, check my profile. I got the letter off of Sue Barr's website. I
just got a letter from the insurance confirming they received my appeal and
if there was any other information I wanted to submit I could do so and I
would get an answer in 15 days. I found a commentary by Dr. Capella
concerning why some have loose skin after weight loss and some do not, I
have that on my profile also.
— bbjnay
June 23, 2003
When I got my denial, I appealed over the phone, but then I wrote a letter
and took my own pictures. I stood sideways and put my arms under my fat to
show how much skin there is. I took every angle possible and wrote a letter
stating that this is NOT for cosmetic reasons. I told them that I had a
breast reduction in the past and prior to taht I always had the fungal
infections under my breasts and I didn't want to go through that pain
again. I have pictures of my skin if you want to see them, email me. No,
it's not a pretty sight, but you could use it to judge if you have more or
less than me. Good luck...
— candymom64
June 23, 2003
All of those doctors who are willing to write letters, should. That is the
part they are looking for. Make sure they state all of the medical problems
you have, including rashes, back pain, unable to exercise. It helps if you
write a letter on how this extra skin is affecting you physically and
emotionally. They are looking for "medical" necessity, so the
psycologist probably won't help, but it won't hurt to add it. I used to do
this type of medical review for 6 years. GOOD LUCK!
— ZZ S.
June 23, 2003
was talking to my sister when I read her your question, She suggested that
you ask CIGNA if they do prosthetic repacement for following removal of a
testicle for cancer! she said that if they do, that will be your
"in" (precedent setting). The insurance companies have been doing
that type of surgery for many years, long before they paid for breast
reconstruction for mastectomy patients. Good luck! Sue-Ellen
— Sue-Ellen J.
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