Diana's abdominoplasty/hernia repair insurance journey

[DianaCox]

I have sent this information about Plan F to the BCBS Medicare guy, as well as reminding him that I'm awaiting the EoC I requested.

This is what I found in the Medicare exclusions:

"Cosmetic surgery or expenses incurred in connection with such surgery is not covered. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member. For example, this exclusion does not apply to surgery in connection with treatment of severe burns or repair of the face following a serious automobile accident, or to surgery for therapeutic purposes which coincidentally also serves some cosmetic purpose."​

I just have to find a suitable therapeutic purpose for other procedures?

BCBS is still considering the request for preauthorization of the various procedures - maybe it will be done by tomorrow, most likely Monday or Tuesday. The surgeon submitted it for a one full day stay, in order to GET preauthorization - apparently, they can keep me 23 hours without preauthorization, but then MIGHT deny the procedure codes - F that! I agreed they should submit for an actual hospitalization to make sure I am not screwed AFTER having surgery.

One of the procedures they submitted for was fat transplantation to my butt, with the thought of adding some cushion for my poor beleaguered and unpadded tailbone. In the meantime, I have been approved for RFA (radio frequency ablation) of the tailbone pain nerves - which would be fine IF that procedure lasted for more than 6-8 months, which it doesn't. I can't see doing that every 8 months or so for the rest of my life. Makes me wonder if at least part of a butt lift might be justifiable ... but I assume that the odds are that won't help either, and I'm not sure I'm up for the pain involved in recovering from a butt lift, even though I "need" one pretty badly. Thighs too. But I'm not sure there is a remotely therapeutic reason for that.

 

[DianaCox]

And just a bit more from the Medicare Guide:

"After a beneficiary has been discharged from the hospital stay in which the beneficiary received non-covered services, medical and hospital services required to treat a condition or complication that arises as a result of the prior non-covered services may be covered when they are reasonable and necessary in all other respects. Thus, coverage could be provided for subsequent inpatient stays or outpatient treatment ordinarily covered by Medicare, even if the need for treatment arose because of a previous non-covered procedure. Some examples of services that may be found to be covered under this policy are the reversal of intestinal bypass surgery for obesity, complications from cosmetic surgery, removal of a non-covered bladder stimulator, or treatment of any infection at the surgical site of a non-covered transplant that occurred following discharge from the hospital. However, any subsequent services that could be expected to have been incorporated into a global fee are not covered. Thus, where a patient undergoes cosmetic surgery and the treatment regimen calls for a series of postoperative visits to the surgeon for evaluating the patient's progress, these visits are not covered."
​

However, I thought intestinal bypass surgery (e.g., DS) WAS a Medicare-covered benefit.

 

[southernlady]

However, I thought intestinal bypass surgery (e.g., DS) WAS a Medicare-covered benefit.

It is. But they still consider anything other than a pannectomy as cosmetic. And it is just excess skin removal, not making it look normal.

 

[DianaCox]

I'll have to see if I can get it sooner rather than later then. Assuming I can bring myself to subject myself to any further procedures. I'm trying to imagine if my vanity will get the better of me if my abdomen looks significantly better than it does now, and my ass and thighs still look like a folded pool of partially melted wax, or an elderly hairless shar-pei. For now, I at least match ...

Called BCBS preauthorization at 4:30 PM their time today - still no answer.

 

[JackieOnLine]

I'm trying to imagine if my vanity will get the better of me if my abdomen looks significantly better than it does now

you know what? you look fine - I've seen photos. so my advice (worth exactly what you paid for it) is strongly consider just stopping and deciding you look FINE. because I'll bet anything you do.

 

[hilary1617]

^^^^^ Yes, this! I've seen you in person and photos and you look great! No need for enhancement!

 

[Charris]

wow diana. The struggle is real. Get them

 

[DianaCox]

Step by step updates:
On Monday, I was told that the initial submission was denied on 3/20, and it was resubmitted for two codes (?). Nobody would tell me anything else, and my request for callback was ignored. So I went apeshit on them this morning.

I was told the procedure was denied. I demanded to speak to the Medical Director.

I then got a callback from precertification with the authorization code for the hernia repair - and a panniculectomy. What?? A panniculectomy is ONLY skin removal. I don't want that. I need the abdominal muscle plication - that is the whole friggin' purpose of doing the more extensive procedure, in particular repairing the hernia without mesh. And the approval didn't mention the removal of the lipoma either.

I am now waiting for clarification of what I have been approved for.

 

[DianaCox]

YOIKES!! I just got off the phone with Carefirst, and I've been approved for the procedures that the surgeon requested! They forgot to add the lipoma-ectomy, but they are adding that. I don't understand how the surgeon is going to get away with doing the abdominal muscle plication, but I assume that the surgical approach is up to him, based on approval for the hernia repair. And they agreed I needed skin removal, so that was potentially more the cosmetic issue, I think.

I was denied for the butt lift and thighplasty, but that's fine for now. I'll address those by appeal while recovering from the abdominal surgery.

Now I need to talk to the surgeon ...

 

[Susan in Tennessee]

Wow, DianaCox, that's a huge victory! I hope things continue to work out.

 

[southernlady]

YOIKES!! I just got off the phone with Carefirst, and I've been approved for the procedures that the surgeon requested! They forgot to add the lipoma-ectomy, but they are adding that. I don't understand how the surgeon is going to get away with doing the abdominal muscle plication, but I assume that the surgical approach is up to him, based on approval for the hernia repair. And they agreed I needed skin removal, so that was potentially more the cosmetic issue, I think.

I was denied for the butt lift and thighplasty, but that's fine for now. I'll address those by appeal while recovering from the abdominal surgery.

Now I need to talk to the surgeon ...

Get on the schedule ASAP. Don’t let time run away from you and bump into Medicare.

 

[DianaCox]

I sent a detailed letter to the surgeon's insurance person, and asked her to ask him specific questions:

Can I safely assume that 49560 (hernia repair) covers the repair of the hernia by whatever means the surgeon thinks is appropriate, including, e.g., muscle plication? If the answer is yes, then as far as I’m concerned, that is a good enough approval. The approved codes thus would cover the hernia repair per se (49560), including by the method of plication of the abdominal muscles, and including the umbilical repair/repositioning if necessary (e.g., because Dr. J suggested I have a new/re-torn umbilical hernia), and the 15830 code covers the panniculectomy; assuming Danielle added 21931 as she said she would do (covering the lipoma removal), we are good to go.

Can you please have Dr. J confirm that we are good to go for:

• Incisional hernia repair (one or more) by abdominal muscle plication, NO MESH
• Concomitant re-repair of umbilical hernia (and repositioning/removal of umbilicus as necessary)
• Panniculectomy
• Lipoma removal

He will call me tomorrow. The surgery can be scheduled as soon as Wednesday next week.

I have the option of adding an additional self-pay procedure (charged only for surgeon, anesthesiologist and OR time) than I am considering, but not terribly seriously - I don't want a breast lift, even though I need one, but I would REALLY like it if the side ****age that spills over the side of my bra could be tamed. It's not only really annoying, it requires the use of bras that are big and uncomfortable. He proposed to lipo my sides next to the ****s and backfat right next to it, with no skin excision, followed by pressure bandages to get the skin to "stick" better to the underlying tissue, but I don't know if that is going to help enough to be worth the money or the pain. To me, it looks like it's mostly skin. And I don't want to risk lymphedema. I have to talk with him more about this before agreeing to it.

I'm going to immediately get an order for bloodwork to check my iron and protein levels - if iron is low, I will demand an immediate iron infusion. However, my levels were pretty good (ferritin was 154 (normal range 15-150 ng/mL) last September. At the same time, my protein levels were OK (PROTEIN, TOTAL, SERUM 6.5 6.0-8.5 g/dL; ALBUMIN, SERUM 4.1 3.6-4.8 g/dL), but that could be really different as I have not been eating the same way - my nausea makes it more difficult to get my protein in.

So do preliminary blood tests, and then no matter what, start pounding protein (add at least one Unjury chicken soup jolt per day for an extra 21 g). I have plenty of the Unjury for post-op.

I'm getting scared.

 

[DianaCox]

As a side note - the surgeon and I briefly discussed (and he submitted for but was denied) a butt lift and fat transplantation to add some cushion around my poor tailbone (the steroid ass shot back in January only lasted about 10 days, and I have since then had another appointment with the pain doctor - he is recommending Radio Frequency (nerve) Ablation or RFA, which sound like overkill, except that it actually is UNDERwhelmingly effective for the amount of - literal - pain in the ass of getting it done, because it only lasts 6-8 months on average - it has to be redone repeatedly. I can have it done without sedation if I'm up for it, but I don't know if I'd want to do that either. Argh.

But I'm wondering if, during THIS upcoming operation, if he can inject some of what he removes from one place and plump up my tailbone adjacent regions?

https://www.realself.com/question/m...ian-butt-lift-coccyx-pain-adding-cushion-back
https://www.realself.com/question/m...-amount-weight-loss-fat-injected-the-buttocks
https://www.realself.com/question/b...ransfer-option-treat-sacrum-tailbone-sticking
https://www.nygplasticsurgery.com/fat-transfer-lose-it-and-use-it/
https://www.eppleyplasticsurgery.com/18726-2/

And how about doing that liver biopsy at the same time too?? I want to get all this **** done at once.

 

[JackieOnLine]

I'm getting scared.

well, at least I know the correct answer to that: it's surgery, of course you are scared.

but, seriously, way to make things happen!

 

[DianaCox]

Kind of irritated. It is Friday night before a holiday weekend. The surgeon was supposed to call me yesterday and today, and I didn't hear from him. I STILL don't have the answers to my questions. So I'm not sure about ANYTHING, including whether I'm going to consent to the surgery based on his assurances about what he's going to do and that the insurance will cover it.

In the meantime, I've gotten the results of my LFTs from the Tuesday blood draw (related to my liver issues, which I was a bit concerned about aggravating with anesthesia, etc.,) but they were great!

3/27/18 .. 23 ............... 44 ......... Both essentially NORMAL!?
Reference ranges are 0-40, and 0-32, so the 44 was a tad high but nothing to worry about.

I guess I'm not getting that liver biopsy any time soon.

The liver specialist had also ordered a few additional tests, a couple of which I wanted to know about for my surgery - my protein levels are adequate (which is good, considering slight nausea issues), and I got my iron panel drawn today.

Protein, Total (Reference Range: 6.0-8.5 g/dL) 6.2 NORMAL
Albumin (Reference Range: 3.6-4.8 g/dL) 4.1 NORMAL

Now I'd like to hear from the surgeon over the weekend - is that too much to ask??