TT, MR and Umbilical Hernia Repair APPROVED!!!! - Portland, OR

I am not sure where to story is...

I am not sure where to story is simular to most of yours. I am 41 years old, married with two kids. I used to have a flat stomach in my 20's but after having the kiddos, it went downhill from there. I exercise 5 days a week and just cannot get rid of this extra skin and fat. I had my BR in July and am feeling well from that surgery. So at my follow-up appt with my PS, I asked him for info on a tummy tuck. He gave me the necessary information and checked my tummy to see if I was a good canidate. He said everything looked fine to procede with the surgery but I would need to have my umbilical hernia repaired. I said "What hernia?" He said it was small but should be fixed along with the tummy tuck. I do know that I have been having pain near my belly button for a few years now but never thought it was associated with a hernia. So he referred me to my GS to have it looked at. Both surgeons will do the surgery together. I am penciled in for Dec 21st. But now I am waiting for both surgeons to submit the necessary paperwork to my insurance and I am hoping they will approve it. I have looked at my insurance coverage for abdominoplasty and it clearly states that Abdominoplasty is considered medically necessary only if your pannus is hanging down below your pubis OR you have MR with a true midline hernia (umbilical or ventral).

Does anyone else have BCBSIL PPO that is having the same surgery I am that has been approved for this? What codes were used? What documentation did they need to approve it? Any info would be very helpful. Thank you!!

I am in California and have Blue Shield HMO and was able to get approval. The approval is for hernia repair and diastasis repair. The skin removal is extra. I also got approved for a tubal since I was going to do it at the same time. But I have decided not to add that to the pile. Now, my girls are almost 2 and I have been going to my GP all this time asking when will my stomach shrink, what about this hernia, do you think I have a diastasis (after finding about that on the internet) and how can I help this intense back pain!? At first I just wanted help. She told me after I stopped breastfeeding I could starve myself. (Exact words) The she kept telling me my diastasis would close. Until I lost all the weight she didn't seem to care. Well, I made sure to get these complaints on paper every time I went, so there would be a history. My insurance is very clear that abdominoplasty is a cosmetic procedure EVEN IF a diastasis exists. I met with a few PS and just had no way to come up with money. Dr. Grant Stevens in Marina Del Rey, CA was super-nice and very helpful. He said if I had a PPO, even out of state, he could probably get it covered. But I had HMO. So you may want to consider calling their office to see what you can find out. So I went back to the beginning. I had my GP refer me to a surgeon for the hernia. He said fixing my hernia, although bad and with a stitch from a prior repair about to bust out of my skin, would be pointless as I have a 5-6 inch diastasis! It has actually been increasing in size as I have lost weight. So he referred me to a PS he is friends with, in my network. Brian Cox in Pasadena, CA. They decided to do a tanThey got it covered. So the surgeon is fixing the hernia and at the same time the PS will fix the diastasis. The PS said no way the insurance covers skin removal unless you have a history of sores and infection under the flap, or if it hangs below VJ. So, once my huge diastasis is closed, I may have that kind of skin hanging, but no pre-auth on a guess. I am going to pay the difference if I can get them to let me make payments. They are very agreeable there. ANywhoo, long story, hope it helps anyone. Feel free to message me or whatever. I hope you can make it happen!! :-)
Oh and the reason my insurance covered the diastasis (when every assistant at every office said it couldn't happen) was I had an EXTREME diastasis. They all say, "every woman who has had a baby has a diastasis!" Well I found out that they mean 1-2 inches. So if yours is bigger, push for the extreme diastasis thing.
Hi-Thanks so much for the info. That really helps! I looked up Abdominoplasty under my plan and it clearly states that it is considered medically necessary and reconstructive only if there is a diastasis recti AND an umbilical hernia. is not clear whether or not the removal of the extra skin is part of the abdominoplasty too. So I don't know. I am afraid to call the insurance back because I don't want to jinx I will post an update when I find out from the surgeons office. Thanks a bunch!!

I just found out today that my surgery has been...

I just found out today that my surgery has been APPROVED!!!! I am so happy and excited. I was worried that I would have to pay for the tummy tuck portion of the surgery. Now I just have to tell my family that I am having surgery again. My pre op is on Dec 6th so I can go over the surgery details, ask all of my questions and get fitted for the compression garment. I will post pics soon....

Sending hugs your way for tomorrow.

Dr B

Referred to him by a close friend who is also a surgeon. Was impressed by his work and bed side manner too.

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