Thursday, June 11, 2009

Fighting to get Re-constructive surgery paid by your Insurance Company

I fought very hard to get my re-constructive (NEVER SAY COSMETIC SURGERIES) surgeries covered by my insurance company. It is much harder today to get approved. Many people have asked me how I got it approved so I hope this can help you.

I have talked to several plastic surgeons and they all agree…they do not have enough staff to fight for patients to get their insurance company to pay for their reconstructive procedures. YOU HAVE TO DO THE FIGHT!!!!!!

First make sure there is not an exclusion in your policy, if there is…you probably do not have a chance of getting it approved.

Remember these are surgeries, it can be very painful and there can be complications. I had complications with my last surgery but I would do it all over in a second. Research your Plastic Surgeon and make sure they have a lot of experience removing redundant skin and working with patients who have lost massive amounts of weight. You can also ask for references and ask to see before and after pictures. I love my plastic surgeon (Dr. Marisa Lawrence out of Atlanta). You will be spending a lot of time with this surgeon make sure you feel comfortable.

My Reconstructive Surgeries

1. Tummy tuck and hernia repair
2. Legs and arms
3. Butt and Thigh Lift (or the continuation of the belt lift)
4. Breast lift and augmentation. (I paid for the augmentation)

My insurance company had a yearly maximum out of pocket so I was having 2 surgeries a year for 2 years so I only had to pay it twice. I started October 2002 and had my last surgery December of 2003.

I was approved for the tummy tuck and hernia repair but nothing else. (In 2001 I had an open RNY many times that causes a hernia and the insurance company would cover the tummy tuck while the hernia was being repaired). I had to prove to the insurance company I needed to have all the other reconstructive surgeries.

Document any raw areas, sores and rashes you get from the hanging skin. Also document about the smell and how hard it is to keep it clean. (example the skin hanging from my stomach, it was skin against skin and I would sweat and it would smell really bad. So, I showered multiple times throughout the day). I saw my dermatologist; he documented everything and took pictures.

I got letters from my PCP, OB/GYN and Dermatologist stating I need to have the skin removed for medical reasons.

Remember the insurance company DOES NOT WANT TO COVER THIS!!!!

I was fighting a denial and you only have so many days to fight, (find out how long you have). I wrote a 14 page letter to the insurance company and cc to John Oxendine (Georgia Insurance Commissioner). In this letter I told how hard it was to live with all the excess skin, sweating, smelling, rashes, and how it felt trying to workout with all the skin. I also told how it made me feel mentally, I was married and was ashamed to take my clothes off in front of my husband. It was hurting my marriage, I told them that. I was trying to make the person who read my letter put themselves in my shoes for a minute. I also sent an experiment. I mailed the insurance company and John Oxendine gallon size zip lock bags. I told them to fill them half full of water and tape them between there inner thighs, one at the waist hanging down, one on each breast. Two on each butt cheek and one under each arm and then try to workout in this Georgia heat.

I sent my 14 page letter certified return receipt to the insurance company, they signed for it I got the receipt back and then they denied getting it. So, I started faxing it! I faxed it morning and night until they said, “Mrs. Rock we got it stop faxing it”.

I also, started writing John Oxendine a letter every day for 30 days, until he put an agent on my case. When he did they called me and said, I don’t know if it will help because your insurance company is “self insured”. Well, three days later I was approved for everything!!!!!

I don’t know if your outcome will be as good as mine….however, I was not going down without a fight! And neither should you!!! You will get out of this what you put into it!!!! So, don’t go away when the insurance company says NO! Dig in and prepare to fight!!!!

Good luck and I hope you have a great outcome.

Take care,