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Insurance Covered my Reconstructive Plastic Surgery

Alright, I know this is the topic that everyone has been waiting for me to discuss. How I got my insurance to cover my plastic surgeries.

Let me first say that I have largely waited to talk about this very publicly until after the surgeries were done and after the bills were all paid. But I’m pretty comfortable at this point so I’m willing to discuss it a bit more. Let me say as an early Disclaimer; I was told every step of the way that my insurance would NOT cover these surgeries. I have been told by every professional involved that this was an unprecedented occurrence.

I also, knew very early on that having these skin removal surgeries was going to be a necessity for me for several reasons. The excess skin caused me pain and rashes that made exercise very difficult and that was problematic both for my weight loss, weight maintenance and my future career as a personal trainer. I knew from the beginning that if my insurance did NOT cover these surgeries I was going to have to figure out a way to pay for them.

So let’s talk first about what I was told by my insurance company and doctors going into this. I was informed by my insurance company that there was no coverage for elective plastic surgery and anything that was not “Medically Necessary” was considered elective. I was informed by both my Bariatric Surgeon and my Primary Care Doctor that I would have issues with excess skin. I was informed from as early out as the Orientation Seminar I had to attend that the only Reconstructive Plastic Surgery they were seeing the insurance companies approve was the panniculetomy; The surgery that removes the rather large part of the “stomach” that hangs down over the abdomen called the panniculus.

Prior to selecting a surgeon I consulted with two different plastic surgeons that I had heard speak at orientation seminars. Both plastic surgeons provided me with the same basic information. I’d be looking at anywhere between 3-5 different surgeries and my insurance would only be expected to cover the panniculetomy portion of the surgery.

Now the first big decision that I was faced with was what surgeon I was going to go with. I’m going to be perfectly honest, and though I won’t name the surgeon that I did not use, my reason for deciding not to go with that surgeon had to do with the fact that his surgery coordinator when I tried to discuss with her how I felt my insurance needed to be approached in regard to billing and about extenuating circumstances that I felt could very well lead us to getting the insurance to approve more than what anyone else expected, her response to me was “We don’t do it that way.” After speaking with the woman personally later and telling her why I chose a different surgeon she apologized for her words and informed me that I misunderstood her and that she would have done anything necessary to get the insurance approval. Her words didn’t imply that however, and they sent me searching for a surgeon that was going to work with me on working with my insurance. This after all was going to mean the difference of like .. lets just say A LOT of money. Could you blame me?

I decided I was going to consult with a different Surgeon so I contacted one of the other bariatric surgery centers of excellence in the area and asked them who they referred their patients too. That’s how I ended up meeting Dr. Shannon O’Brien at the Waldorf Center. I selected Dr. O’Brien as my surgeon for two major reasons; she was willing to do more work in less surgeries, which overall meant less time and money for me and she was willing to listen to me about the fact that I really felt my insurance should and would, if it was approached correctly, approve my surgeries.

Now let’s talk about my “extenuating” circumstances. I had an incident as a teenager that likely wrote me a fast check to obesity without my even realizing it. After failing physical education my freshman year of High School I had to attend summer school to make up for it. Summer school PE consisted of a 2 hr class that lasted I dunno 8 weeks or something and consisted of pretty much the students walking around the football field over and over again for 2 hours. The Teacher watched, and did whatever he did on his clipboard, planning football plays for the next season, who knows. After about three days of this 2 hr class I started to get a rash on my arms. Next it started to appear between my chest and my neck. Once it started to appear on my hands my Mother took me to the doctor who informed us that I was photosensitive, or “allergic to the sun,” as he put it. This got me out of PE for the rest of my High School career and opened up another elective slot for me which is why I got to do so much academic participation. It’s also probably why I never got a chance to learn that I might enjoy exercise or that I loved to run. I wonder sometimes what would have happened, changed or been different in my life if someone had helped me find my love for running when I was fourteen instead of thirty-four.

This sun allergy never really bothered me too much through my teens and twenties. Being as big as I was it wasn’t like I spent a lot of time in the sun or outdoors at all for that matter. When it did start to rear its head again was when Jason and I were first married back in 2003. We were spending a lot of time outdoors letter boxing when I had lost a bunch of weight and even as I started gaining it back, we still stayed pretty active we just did shorter walks and easier hikes. When we got back from a two-week camping trip in the summer of 2005 and my face looked like something off that movie “Mask” with Cheer and the boy with the distorted head, I knew it was time to start bugging my doctor. After a lot of tests, a Dermatologist finally diagnosed me with Discoid Lupus – in case you aren’t familiar with what that is I have provided a link. Some doctors believe that it was the skin disorder that Michael Jackson had that began altering the pigment of his skin and turned him to plastic surgery to begin with. It is also the same skin condition that the Singer Seal has been diagnosed with. For me personally, it manifested itself in this red bumpy risen rash in any area where the sun touched my skin, where I sweat a lot, or where my skin touched. This became a very problematic issue for me in areas like where my excess skin caused folds. I started to get sores anywhere that my skin touched; under my armpits, under my breasts, between my thighs, on my  mons, on my labia. Even at times on the backs of my thighs and on my stomach itself.

Now at this point, I started laying the ground work for where I knew I was going to be going. Every doctor that I saw, I talked to them about my weight loss and my skin issues and the health problems that it caused me. As an example, I had to see my OBGYN as part of my pre-op medical requirements for my gastric bypass. When I saw her, I let her know what I was about to do. Every time I saw her after that, whether it was for a bump or an annual exam, I mentioned the excess skin issues to her and discussed how they affected my female hygiene. Same with my primary care doctor, anytime I went to see him about anything, I had him document whatever bumps, sores, rashes or other skin irritation I had going on at the time. I talked to my dermatologist, my PCP, my OBGYN, and of course my Bariatric Surgeon. I made sure I took pictures, lots of pictures, of every bump, rash, infection, anything that could be blamed on the excess skin on my body, I documented the hell out of it.

I had talked to my insurance company upfront and they had told me something that I feel was key in our success. Even my surgeons office was shocked at what my insurance company approved. But from the very beginning they kept stressing this to me: My insurance covered nothing pre op and nothing post op, they covered only the surgery at a $25,000 lifetime maximum. They were very strict about this. Very strict. They did not cover anything pre-op for my Gastric Bypass. They also do not cover my post op follow-up after the initial 90 days after surgery. So my one year follow-up and any lab work that has to be done, are all on my dime. The thing I found interesting though, and where I started thinking outside the box was when my insurance said they covered any “Complications” and that the $25,000 lifetime maximum did not apply to covered complications. I asked my insurance company “Wouldn’t excess skin be a complication of Gastric Bypass surgery? I mean I wouldn’t have excess skin if I had not lost all this weight and I’d not have lost all the weight if i had not had the Gastric Bypass.” They didn’t confirm that for me, in fact their answer was sort of vague, but it was enough for me to know that I needed to find a Surgeon who was willing to look at my skin removal surgeries as a medical necessity and as a complication of Gastric Bypass surgery if I wanted to see my insurance cover it.

I shared my suspicious with my Surgeon from go about how my medical insurance needed to be billed and how i thought it needed to be looked at as a complication of surgery that also caused complications with my pre-existing discoid lupus. I’d love to get my hands on the paperwork that went from my surgeons office to the insurance company and be able to say “This is what worked.” All I know for sure is that all three of my surgeries have been covered by my insurance company. I never had to submit any photos or anything like that, I got my approval based on what my surgeon submitted on the first surgery.

The insurance denied us the first time we submitted to them on the second surgery. When I spoke to them, they said that they did not feel there was enough documentation regarding the skin issues that we were treating and asked for more documentation that the surgery was medically necessary. After a discussion with my surgeon where we both agreed that the implants I was planning to get were not medically necessary, but the rest was, she wrote a letter to the insurance company that stipulated as much and within a few days we had the approval and were ready to go. My final surgery, the thigh surgery I just did last week, was also approved on the first try. I never had to submit an appeal or anything like that through the entire process.

Financially, my insurance covered the first surgery at 80%, it covered the second and third surgery at 100% because I had reached my out-of-pocket max for the year. Now people ask me what the plastic surgery has cost me total. That’s really hard for me to answer because there are other expenses than just what you pay doctors. There is also the issue of time off. And I had to take quite a bit of time off after the first surgery. What I can say, is that so far, I took out a loan for $22,500 to fund my first surgery, before we got the insurance approval. So far, we have used the funds from that loan to pay our portion of the first surgery and to cover the time that I’ve taken off for all three surgeries. To date, so far we have used $17,500 of the loan funds. Considering the fact that I fully expected that loan to only cover the first surgery and that we have been able to use to pay our portion and cover my time off from all three surgeries this year, I consider that quite a feat.

I want everyone to understand that I am NOT in any way saying that your insurance will approve your plastic surgeries if you approach things the way I did. I’m 100% confident that it was a combination of my Discoid Lupus causing even more medical issues with my excess skin and it being considered a complication of Gastric Bypass surgery that convinced my insurance to approve these surgeries. That is a very unique combination and one I highly doubt most can mimic. I think the lesson here is that you need to think outside the box and communicate very well with those involved. I think it is very important to have several doctors willing to advocate for you; When I spoke to the nurse that worked on pre-approvals at my insurance company after they denied the second surgery and she told me that they wanted more documentation on the skin issues that the surgery would treat and more clarification that it was medically necessary, I asked her. “Would you like a letter from my PCP. OBGYN, Dermatologist, or Bariatric Surgeon?” I heard her chuckle a little before she said “Any of those would be fine, a clarification letter from the Plastic Surgeon would work as well.”

I believe that insurance companies should be covering these reconstructive surgeries. The emotional and physical benefits from me having these surgeries must out weigh the costs in the long-term. I’d love to see someone do some research in this area to help start to push insurance companies in that direction. What I do know is that my insurance company covered all of my surgeries thus far, and if I only ever had done what they covered, I would be ok with that for sure. I consider myself very lucky to have gotten what I got done with the help of my insurance. I’m also very passionate about trying to make sure that others are as fortunate as I was. So if there is any advice that I can give you based on my own journey, it is to explore every option and communicate really well with your insurance company and Surgeon. Push your surgeon to at least try to submit based on medical necessity and to appeal at least once as well.

That’s my experience with my insurance company and getting my surgeries approved. If you have any questions please feel free to use the comments section and I will try to answer them the best I can!

The Pain of Reconstructive Plastic Surgery

I know that a lot of people have questions about the reconstructive Plastic Surgery aspect of the weight loss journey. With that in mind, as I write about my experience with Reconstructive Plastic Surgery over the next few blogs, I want you all to know that I will do a final wrap up blog where I will answer any questions that you all send in. So if you have any questions about the Reconstructive Plastic Surgery aspect of the weight loss journey that I can answer from a patient prospective, please send them to me at pandora@desperatelyseekingslender.com or leave them in the comment section on my posts.

I’m currently three days out of my most recent surgery, a thigh lift, and as I wrote yesterday, it is by far the most painful of all the surgeries that I’ve done. Today, is better than yesterday. Each day is a little better, today I can walk without having to hold on to someone else and I’m not hunched over in that way that makes you look like a 80-year-old woman with osteoporosis. This is quite an accomplishment for me. I feel like I have made great strides since in three days I’ve gone from “HOLY CRAP THAT HURTS MORE THAN I CAN TAKE IT, SIT ME DOWN, SIT ME DOWN, SIT ME DOWN,” too, “Alright, this hurts, but I can take it and by the end of this year I will be running a half marathon wearing shorts in public. That’s my newest goal. Though I am working on a few.

So to give you guys an overview of my Reconstructive Plastic Surgery Journey, I’m going to give you an overall outline of the process over the last year.

  • 07/2011 – First Consult with Plastic Surgeon
  • 11/2011 – Second Consult with Plastic Surgeon
  • 12/2011 – Consulted with Second Plastic Surgeon
  • 02/2012 – 1st Reconstructive Surgery:
– 8hrs of Surgery, Two days in hospital
– 360 Body Lift
– Butt Lift
– Brachioplasty ( Arm Lift )
– Liposuction on Outer Thigh
– Outer Thigh Lift
– Removed 12lb. of skin
– This surgery had the most complications and was extremely painful.
– My Insurance covered this surgery at 80% with no denial or appeal process needed.
  • 08/2012 – 2nd Reconstructive Surgery:
– 6hrs of Surgery, One day in the hospital.
– Side Gather Abdominoplasty ( Tummy Tuck )
– Breast Lift
– Removed 3lb. of skin
– This surgery had the least amount of complications and was a rather easy recovery.
– My insurance covered this surgery at 100% because I had reached my out-of-pocket max for 2012.
– The insurance denied this surgery when we first submitted because they did not have enough documentation on rashes and skin irritations being treated by this particular surgery. There were also originally a breast augmentation (Implants) in addition to the breast lift. My insurance denied the augmentation but approved the rest once the implants were subtracted.
– We didn’t have to submit an appeal, the insurance company requested a letter from my Surgeon confirming that we were treating area’s that had a history of skin rashes, sores and legions due to skin on skin contact. As soon as they had a letter from the Surgeon stating the surgery was a medical necessity, we received the approval.
  • 11/2012 – 3rd Reconstructive Surgery:
– 3hrs of Surgery, Outpatient Recovery no hospital stay.
– Thigh Lift
– Removed just over 3lb. of skin.
– This surgery was the most painful, and the hardest to get comfortable after, but once you do get comfortable the pain is almost non-existent and VERY manageable.
– My insurance covered this surgery at 100% because I had reached my out-of-pocket max for 2012. There was no denial or appeal process necessary.

Alright, I know that A LOT of people want to know how we got my insurance to approve my Excess Skin Removal. I’ll be doing an entire blog post on just this subject later and will come back and link to it here for those that want to read it. I just feel like that is such an important issue that it should be addressed separately.

Now, I’ve posted blogs after each of these surgeries, or close to it. And I think each of them shows a pretty good example of my emotional mindset during each of these surgeries. When I posted about my first Reconstructive Surgery back in March, the focus of my post was sort of “What can go wrong will go wrong.” and there was a lot of Woe is Me and a lot of feeling sorry for myself. There was also A LOT of complications during that recovery. I had so much swelling that I ended up back in the hospital about 3.5 weeks post op on IV diuretics to try to get rid of all that water weight I had taken on in swelling that wasn’t going down.

The post after my second surgery, which really had no complications other than a little hiccup with my drain site, was much more upbeat and much more “I got this, what’s next?” – that was quite a change in my emotional state of mind. But something that I think is really important to note here is that it was this Reconstructive Surgery in August that really allowed me to look in the mirror and start seeing the real me again. I think that my being able to do that was a pivotal moment in my emotional weight loss journey. For the very first time, after this surgery I started to see the “skinny” and “thin” girl in the mirror when I looked in it that my friends and chosen family all assured me they saw.

This was a huge moment in my emotional journey. It was the first time that my mind raced forward and tried to catch up with my body. I love to run, I get something out of it spiritually and emotionally that it’s hard for me to explain. But when I run, my feet just go, they don’t need my mind working with them, it’s the one time during the day that I can honestly say my OCD mind actually slows down. I get to think, really think about things. What I want to write about, how I feel about something going on in my life. Just as an example, as I sit here today writing this blog from the recliner I am resting in after surgery, I look around me and my first several thoughts are…

I really need to find a way to make that cat box being in this room more discrete. I wonder how soon I can get back to work. I need to not be nodding off constantly first which means I need to ween my way off the Oxy very quickly. I’m really glad that we ended up buying the TV for this room when Heather moved here, it’s been great having it in here after my surgeries. I wish I was making more money at work though, then maybe it would be paid off by now. Oh I bet the no interest on it is almost up, I should look into that and think about moving the balance to another card that will offer me lower interest rates. I think Discover is doing that right now. I should tell Siri to remind me to look into that next week. Where is my phone? Ah there it is. Man I really need to clean my phone. Oh I should clean the MacBook at the same time. And I need to reorganize that laptop bag so it’s easier to find things in. And shoot I still need to send last month’s giveaway present to Joy because I didn’t get around to doing it before my surgery. Maybe I can have Heather do that for me next week. Oh we need some things from the store today, I should make a list so that nobody forgets things, and it’s getting close to the time that we said we’d try to give me my first post operative shower…

I have an entire new “To Do List” to make and it took less than 3 minutes of me sitting here silently. That’s just how my brain works. But when I run, it’s different, I can actually stop thinking about all those things and focus on something like, “I’m angry about this, how should I deal with it.” or “I need to think of some ideas for my next blog post,” or better yet, “I need to find the inspiration for this book I want to write.” When I run, its like my head is clear and I can see clearly without anything getting in the way. The second reconstructive plastic surgery that we did in August, it was a very similar experience for me. The skin that was removed from my body after that surgery let me clearly see what was left behind from the hip up when I looked in the mirror. I could see the skinny me for the first time. I could see the thin girl that I always told people I believed was hiding inside me. It was the same clarity I feel when I run, only I wasn’t moving, so I figure my mind was running, and it needed to, my mind needed to run and catch up with my body and start allowing us both to be on the same page again. It was a breakthrough moment for me.

This surgery, I find myself in a completely different place emotionally. I’m not in a big hurry to look at my incisions like I was before. I’m not in a big hurry to inspect them and scrutinize them, I realize that 9 months from now, let alone a year from now they are going to look completely different. I’ve also decided that I am going to spend 6 months concentrating on body toning to the areas I am unhappy with before I commit to a 4th round of plastic surgery that will be entirely on my dime because my insurance isn’t going to cover anything else from here on out and I’m 100% sure of that. (I’ll discuss this more when I do the piece on insurance aspects of these surgeries, I promise.) I find myself much more positive and patient during this recovery and once again I can only say that my time in Dallas at the OAC Convention and my time in California afterward, changed me. It put me on a whole different path and right now I find myself more focused on healing so that I can get moving on this new career and start working on all the things I want to do to help others with their weight loss journeys.

My emotional journey has been amazing this year. It really has, and I think that journey has been very evident in my healing and recovery after each surgery.

From a pain perspective, I really have to stop and consider which surgery I think was the most painful. For the last three days I have insisted that this one was the worst. But honestly I think that is incorrect. I think that for the last three days I’ve been in pretty excruciating pain, it’s not fun, but each day has been notably better than the day before, and I have been more mobile each day. I hardly have any swelling, maybe a little in my feet, and I couldn’t say any of those things three days after being home from the hospital after my first surgery. I was miserable, swollen so bad I could hardly move.

I have a picture that I sent my mother a few days after the first surgery and the look on my face screamed “I’m in so much pain my eyes are rolling into the back of my head and I’m blinking repeatedly to keep from crying and screaming.” Then I look at a picture of myself yesterday and I can clearly see that I’m not in any pain, I was in a very comfortable position. Now when I move, the pain at first made me cry and made my knees buckle. I guess the most honest thing I can say is this. When comparing the first three days of pain after all three of my surgeries I would say that the Thigh Lift is by far the most painful. I think however that in comparing my pain levels here to the pain levels during the recovery of my first surgery I would have to say the first was more painful.

For the first surgery my pain level for the first few days was around a 7 I think, before pain meds kicked in or if I went too long without them I’d be sobbing and hyperventilating in pain. I had incisions all the way around my body which made it hard to get comfortable no matter what position you laid in you were always laying on some part of the incision. The pain tapered off during days 4-7 but when complications kicked in at about day 15, it was hell, pure hell and I spent a good week coming back from that and fighting a pain level that was a constant 7 again.

The second surgery was a walk in the park, the incisions on the side and under my breasts made it very easy to get comfortable and very easy to stay off the incisions. For the first few days I’d say my pain level was a 6 or so but it dropped off quickly in days 4-7 to like a 4 or so and then within another week it was more like a 3 during the bad times. In the last couple of weeks I’d put it at a one or two though and it was pretty much an easy 6-week recovery.

This last surgery, when you are experiencing pain, it is the most excruciating. It’s a pain level that is like twice as painful as everything else that I’ve been though.  The good news is that you don’t have to be in pain too often. You can avoid the pain a good 60% of the time. By not moving.

At the time of I’m now, 5-days post operative reconstructive thigh surgery I’m still limiting most of my movement to getting up every 2 hours or so and walking to the bathroom. Yesterday I did the whole sponge bath while standing at the sink thing even though I am released for a shower, I know my thighs are not ready for that yet and that my legs needed a couple more days to commit to the promise of holding me up in there. So that’s what I decided to do. I’ve made two big commitments during this recovery; that I would listen to my body and that I wouldn’t freak out over weight gain. I’m doing really good with the first part of that. But my body issues are heavily at play today. I wish I could figure out what is wrong with me, why my head works the way it does, but today I’ve been obsessing for hours about the loose skin that is leftover after the skin relaxation of the first surgery. I also did my first walk de la apartment, that’s my little official lap from the guest room door down the hallway into the living room so I can see all the Christmas decorations we have up and then back. It’s not far at all, maybe 100 ft. total. But it’s my first walk, and it was an accomplishment for me. Now I’m back in my “recovery recliner” admiring the pretty little Christmas Tree that Heather took the time to put up for me to make sure I got to enjoy the holiday season while I’m stuck in here recovering.

Tomorrow I plan to do 2x the laps I do today, so probably 3-4 tomorrow. Plus tomorrow is going to be a full on shower. Then I have my follow-up with Dr. O’Brien on Wednesday the 5th. Tonight, I’ll be watching TV, focusing on pain relief and enjoying Authentic Lebanese Food from one of my all time favorite Portland restaurants, Nicholas. If you are in Portland and do not eat at this restaurant, you’ve committed a crime. From their Lentil soup to their, whole wheat pita bread to their lamb pizza, EVERYTHING is delicious. Man, with as much as I mention all the companies I love you’d think some of them would start to love me back. LOL, fat chance.

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Author: Pandora Williams

Author of Desperately Seeking Slender

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