Medical Criteria

[Guest guest]

<< they probably

have the criteria in their offices already from BCBS. >>

I have already had the consult and am scheduled for surgery on 6/1. I was

denied for the predetermination of benefits and was told by BCBS that I could

appeal that as well as the payment of benefits after the procedure. It is an

uphill battle but I get so frustrated when I read of others who have been

successful in insurance payment for tummy tuck and they do NOT have rashes,

etc. I think that the insurance companies automatically deny when they see

the physician is a plastic surgeon and spit the claim out as " cosmetic. "

After all, there are absolutely NO plastic surgeons on my preferred provider

list. I know that I have heard several times that if denied for WLS, one

needs to request from the ins. co. the exact verbage of their coverage in the

policy so that Walter can help them fight the denial. I am only asking for

that same thing....exact verbage. Granted, I already know that I would not

have battle if I had infections. However, I am NOT going to wait until that

happens. In the meantime, I did contact the Indiana Insurance Commission and

they are sending me a form to file an official complaint and they will

intervene on my behalf. Apparently there is no statute to cover this

situation in the IN law, but the woman I spoke with felt that I had a

legitimate complaint. I have also faxed a letter to my PS asking him to

request the information himself from BCBS. In the meantime, I will just

start the appeal process without the information I wanted.

dawn