18months Post: BRM, Panni/TT with Lipo (insurance covered it all, but Lipo).

I'm 5'2" and currently 160 and dropping. If you subtract the weight my PS wants to take off my boobs and my apron, we're actually looking at about 148 :)

So far my experience has been a roller coaster and I've not even had the surgery yet! If it's all covered I know for certain that it will be worth it.

I've had quite large breasts since the age of 16 and the tension headaches/neck/back pain as well, I distinctly remember trying to get a strapless bra for prom at Victoria's Secret (back when they used to have real sizes) and being told that I was a 36DD, but I could easily wear a DDD. Thank god for Marching Band and being a concert instrumentalist, without that I'd probably have such poor posture that permanently curves my spine.

I've always had a little bit of a weight struggle - my weight fluctuated from it's low of 135 (in high school) to upwards of 190 (as a senior in college). My average has always been about 150 and I have huge tatas and large, muscular thighs and I've always had a little "pooch" in the lower abdomen.

After graduating college in 2004, I maintained a weight of 150 for a few years and that is what I weighed when I met my future husband the following year. I began taking birth control in 2005 since this was my only serious relationship and by the time I was shopping for a bra for the wedding in 2008 my bra size was up to a 36G. My weight had gone up and then back down as it does with a new relationship and I was at 149 on my wedding day. That was the last time I was under 150. All the while my tatas never changed size, I'd be a happy girl if I lost weight in my boobs!

Not too long after our wedding I'd gained 20 pounds, I'd say within 3 months. I worked really hard at the gym, I would go to jazzercise 6 times a week for 45-90mins each workout. Nothing helped the weight come off so just before our 1st anniversary, I had my Thyroid tested, while it was in the range of normal it was still skewing to one side and I was prescribed synthroid and the mother of all diet pills, Phentermine!

I lost 10 pounds in the first week. Since it was really expensive to see the Dr. who was prescribing the pill and my husband and I decided to have our first child, I stopped taking the phentermine. But that 10lb weight loss triggered my body and I was immediately pregnant.

When I found out I was pregnant I was about 170. During the first trimester I lost 5 pounds since I changed my eating habits...lots of small meals, lots of extra veg and fruit, to be extra healthy for baby. I woke up the morning of my second trimester and I gained 25lbs overnight. I'm not kidding it was that fast, I literally went from having lost weight to my joints and muscles aching because of the extra weight. No matter how I proceeded at this point I couldn't stop gaining weight and at the end of it I was up a total of 65lbs! I was at 230 right before delivery. (This happened to my mother when she was pregnant with me, but when you start at 90lbs, it's not a big deal!) I knew I was going to have a skin apron by the time I hit the third tri, I hadn't even reached terminal weight and I had a huge apron.

Once my boy was born via emergency c-section in Dec 2010, I lost the first 40lbs of baby super fast, like in a month. It was an amazing feeling, however the last 25 hung around and I'd had a few extra pounds on me to begin with. I went back to the doctor in Dec 2011 to test my Thyroid and get phentermine. Again I lost 10lbs in the first week! It was such a great feeling I was at 173 for my son's first birthday, only a few pounds shy of pre-baby weight. I was trying really hard to get my headaches under control, exercise and get 20 more pounds off when...

I found out I was preggers again on New Year's Day!! I know, I'm really fertile, I was on birth control and I was taking a class 3 narcotic. I immediately stopped the Phentermine, the pill and my headache meds and started freaking out that I'd already done damage to baby 2! Turns out I wasn't very far along at all and baby girl is perfect! With her I only gained about 30lbs and I lost almost all of it by March of this year. Then LENT. Seriously I gave up fast food, sodas and chocolate - AND I gained 14lbs back.

I was pretty depressed and said F it for another month. My daughter was getting less and less interested in nursing and more interested in food, but I was hoping to get her to a year. Around 2 months to her birthday, I really started working out a lot and restricting calories. I joined GymPact and logged everything I ate with LoseIt! Since she was giving up on nursing anyway, I wasn't too concerned with cutting back on calories and by 11m she was done and I'd lost 7lbs. I went the next day to my PCP and luckily he agreed to give me the RX for phentermine and suggested that I do it for the full 3 months (you have to go back every 30 days because it's a controlled substance.)

I decided I was only going to do 2 months and get the 3rd month and use it at half dose to ween myself off and save a couple of pills for Christmas and Thanksgiving. Well I didn't see as fast of a result this time with the Phentermine, it was actually a little discouraging because I'd seen such dramatic changes the first 2 times I'd tried it.

But that's because I hadn't changed my habits prior to the Phen the first 2 times. This time I was already doing what the pill would make me do. For me this time around the pill just made it easier to STICK with the low calorie diet I was on. See, I could literally eat all day. I think about food constantly and that's what Phen does for me. It takes the thought of food out of the equation.

I'd always known I wanted a Reduction. I never knew I'd need a panniculectomy/TT. I've got it on good authority, thanks to 2 c-sections, that I actually have a pretty tight abdominal wall, but the skin flap is unbearable. I can't wear any pants unless they're 50% spandex or 4 sizes too big.

Here's where the roller coaster begins. I called the PS I wanted to use, Dr. John K Long of Houston. (I had a girlfriend who had 2 c-sections as well and went to Dr. Long over Christmas 2009 to get a panniculectomy - she was back at work, light duty, in 2 weeks. I couldn't believe it! I knew I had to use him, if it came to it.) I set up a free consultation and I was an excellent candidate for the panniculectomy and breast reduction. He said he'd remove 500g from each breast...that's a total of over 2lbs of my chest! They told me from there what I needed to do to get going on getting the insurance's approval.

I had to go to my PCP and get them to back date the referral to the date of the consultation, plus I needed at least 1 letter of medical necessity. The PS gave me a couple of sample letters to help my doctor(s) write the LOMN. Well, I saw my PCP and he said he'd send the referral but not my letters. I was a little taken aback since he'd been seeing me pretty regular with the Phen and I'd told him of my plans to apply for approval for these procedures.

After the "fail" with my PCP, I went to my OBGYN and she said she'd write whatever I needed for the stomach and boobs, and send it over. Phew, well at least I had one letter. I decided I should get a second letter since I couldn't count on my current PCP. I went to my old Dr. who'd seen me as a child, through puberty and up until I got married and moved across town. He only wrote a letter for my breasts, specifically noting my asymmetry (left is 1.5 times larger and 2lbs heavier than right).

I followed up a few times the week of 10/14/13 with the PS to make sure they got all my info and that it was sent off for approval. On 10/24 I got a call from my Aetna nurse coordinator...

My panniculectomy was APPROVED!!!!! But my breasts weren't?????? Let's see, tell me how that makes sense? I have a 15 year history of chronic neck/back/shoulder pain and I've seen eye doctors, dentists, chiropractors, massage therapists, well, you name it to try and treat my weekly Tension headaches, but that's not enough evidence, even with 3 letters of medical necessity (including the PS's)????? BUT my 3 year old skin flap, which I only had 1 additional letter for, plus a short hand note from my current crappy PCP, was approved?!?!?

Obviously I was shocked. I thought I'd be fighting a different battle. I really thought I'd be fighting for my stomach and not my breasts, that was a no brainer. I'm a 34H and I'm 5'2. Regardless of how much I weigh that cup size is too big for my frame. The Aetna nurse told me it was only denied because according to Aetna, based on my height and weight, I needed to remove at least 650g from each breast...She said, just go back to the PS and see if he'd be willing to talk with the review person and explain his case and maybe up his estimate or up the amount he'd be willing to take out.

She also told me that 3 operational codes were submitted - breast reduction mammoplasty (denied), panniculectomy (approved), and abdominoplasty (denied). I didn't know they were submitting the TT - I could have told the PS that it'd be denied my Aetna flat out, every time because the code for that is listed as strictly cosmetic. I was a little frustrated because I was trying to figure out why the submitted a TT when that's not what I asked for - I knew the difference going in.

So I immediately called the PS. My immediate concern was the Boobs. I relayed what the Aetna nurse said about taking out more and talking with the reviewer. And then I said, I need to know how much it will cost IF it's not approved. Then my next concern was the TT added on to the panniculectomy. I tried to get a straight answer on the phone, am I REQUIRED to have the abdominoplasty, if I'm having the panniculectomy????? She just kept telling me not to worry about it. Well that really didn't help me very much, since I was already majorly stressing about the boobs.

So I'm out running errands the next day and I get a call from the PS. She said that Dr. Long didn't think the review would do any good since he didn't think he'd be able to take out more, enough to make them overturn the pending denial. Well that alone made me feel a little hopeless, I understand that Dr. Long is very busy and that he shouldn't waste his time. I'm sure he's had this sort of experience before and knew what the outcome would be if he couldn't go to the table with some compromises. I trust him, but I was still disheartened.

So to that I asked "since I'm getting the panniculectomy, there's cost that over lap, right? OR, anesthesiologists, etc? HOW MUCH will it be out of pocket, taking into consideration it's a piggy backed procedure?" To which she said "$6700". I tried to clarify at that time that it was in fact the additional costs after taking into consideration my other procedure, but I wasn't thinking very clearly and was beginning to break down.

So then I tried to clarify again, did I need the abdominoplasty if I had the panniculectomy? Is it required? She started talking about codes and the insurance company, and I said I know what codes and which is approved and denied...I HAVE TO KNOW is the TT required as part of the panniculectomy? And how much will it cost me?? She said she'd call me back soon, but I should get my appeal letter ready and send it to her asap since we weren't doing the review.

Here I am in the middle of Home Depot having a mental break down with both toddlers in tow, because even though I got the tummy procedure approved it looked like I was still going to have to pay for it, to some extent. I really thought the overlap was going to be much bigger where the breasts were concerned, so that nearly $7k figure fried my brain. And all I could think was that the TT was going to be something astronomical, even given the panniculectomy was covered.

I could barely hold it together as I left the store. I tried calling my husband and emailed my mother. I just couldn't believe, all this way to get the apron approved and dangled in front of me, but to have it snatched out of my hands because it seemed to be lumped with the TT. I'd already underestimated price greatly and I wasn't going to make the same mistake again. I was just going to spiral downward into depression.

I wanted to start my letter but I didn't know where to begin. So I called the Aetna nurse back, since she said that if I had any questions I could just call her. My main question was, do I make an emotional appeal with the letter, at the risk of sounding superficial, or go strictly factual? But I barely got the question out before I started sobbing hysterically on the phone, asking how they could deny a 15 year history of tension headaches and that I meet all qualifications, except the amount to be removed by 18%.

The Aetna nurse is really awesome, she actually works for a division directly devoted to my husband's company and was pretty shocked that I was denied in the first place. She said that obviously this affects me deeply and that speaks to my quality of life. She told me to lay it all on the line, since I didn't have anything to lose at this point.

I wrote my letter, I began with a very emotional plea, emphasizing the hopelessness I was feeling. Getting this letter down was very cathartic and it gave me something to focus on the rest of the day, instead of moping. My letter is 3.5 pages, as I said it start with emotion but gets straight up in their face with the facts, I went point by point on their Clinical Policy Bulletin and outlined all my symptoms and how long I've self treated, how many doctors I've seen, how many OTCs and RXs I've taken...I'm hoping that based on the poor quality of life since the age of 16 coupled with the overwhelming factual evidence, they will have no other recourse but to reconsider.

The main points that I addressed in my letter were regarding the psychological scaring from massive tatas at a young age, how my tatas and borderline body dysmorphic disorder affect my relationship with my husband, my mother's breast cancer history, my sleep issues, asymmetry, and tension headaches. You see, according to my Aetna nurse, even though I know a few of these items were mentioned in various letters, the ICD-9 codes (reasons for medical necessity) weren't referenced on my pre-cert request. And the headaches are the MAIN reason I want my tatas reduced. I've got headaches weekly and I take 2-6 pills daily to combat or eliminate them.

After I've drafted the letter, I read it to my husband. It was midnight or so and he was pretty tired, and then he says, "how long was that?!?!" He was worried it was to redundant or emotional, so I went over what the nurse said. The doctor's have sent the medically factual letters, it's up to me to make the emotional appeal and that's what I did. I stressed and stressed the issues I have and have had over 15 years, hoping that Aetna will realize how much they're actually spending on treating the symptoms of a relatively easy fix.

I sent the letter to the PS office and called the following morning to check that it was received. I didn't want them to think I was hounding, but you know how emails are, one wrong character... So the staff member who answered the phone said can she call you back?

An hour later, while I'm walking around the mall with my kids, I get a call. It's the PS office and FINALLY I have some good news, the TT in conjunction with my Panniculectomy only costs me $500 out of pocket. I'm getting MAJOR cosmetic benefits for $500, that's less than a third of what it costs for stupid Ionithermie (which doesn't work) at the medspas!!

I finally got the answer to my question, NO the abdominoplasty is not required, but if you want the best results it's highly recommended. Even though cost was no longer an option, I needed that answer...it was just driving me insane.

So, this is where I'm at now. WAITING for the insurance to finalize the denial so that we can begin the appeal process. My appeal letter is sent off and ready for the second we get the next green light. My mom has given me a little hope, she was denied with both of her surgeries on the first applications, but eventually it all worked out. I'm trying very hard to be optimistic about this, but I don't want to get my hopes up too much.

I just got my approval letter for the panniculectomy and my denial letter for the breast reduction and abdomniplasty.

I've sent my appeal letter and the denial over to the PS office so they can file the appeal. Fingers crossed. I'm hoping that since I've lost a few more pounds since the initial pre-cert request that it may be turned over. Literally the only reason they won't approve my request is that they don't think the PS is taking enough tissue out of my boobs. They require nearly 650g each, based on my BSA, and he applied to do 500g each. This is a 30% difference, but my height was listed wrong and I've lost 7 lbs. That drops me down to 1.74 BSA and Aetna only requires you remove 590g each - now we're talking about a less than 20% difference. I meet every other qualification, over and beyond.

I asked them to consider that they did approve my panniculectomy and that's a significant portion of skin/fat to be removed and would lower my weight a little more.

So...I had a few more thoughts about my surgery and although I thought I was prepared going in the first time, I have a bunch more questions. Frankly I didn't want to go gung-ho with my first appointment because I didn't want to get my hopes up in case nothing was covered.

So there's 3 scenarios:

1. Breast Reduction denied. So I only have the TT/Panni done on 12/13. This will only cost $535 after insurance covers most of it.
A.) my PS doesn't automatically do lipo with the TT/Panni, so I'm going to see if he thinks I need my flanks lipo-ed. If so, how much extra that costs ON TOP of the $535 I'm spending. I'm worried that my "love handles" will stick out a lot more after the TT/Panni without the flanks being done. I figured if this was necessary based on my current shape that he would have recommended it, but I don't want to assume.
B.) I'm going to also ask about a small amount of lipo on my inner thighs. I just CAN'T get rid of that little jiggle on the inner thighs and I've been in my MBTs and walking since March...I've lost and inch but it's not firming up. I'm not trying to go crazy here, but while I'm under the knife I may as well get everything done, with in reason if I can afford it :)
C.) My bingo wings - HA! They're not that bad, but I'm 31 and constantly lifting babies and they haven't improved either. I'm going to try the homemade body wraps (for my inner thighs as well) to see if it help, otherwise this is an option. If the cost on the lipo on increases a little per each body part (based on time and equipment use) it seems like it would make more sense monetarily to get it all done at once, but I DEF don't want to stress my body too much...this is all just conjecture at this point.

2.) Breast reduction (includes lift) is approved after 1st or 2nd appeal, before 12/13 and I go ahead with the TT/Panni and the BR - BEST CASE SCENARIO!!
A.) Still want to see about the flanks, it's top priority as I don't want my back/middle to look funky after having all the hard work done!
B.&C.) Not nearly as important - so unless the cost is minimal I'm that worried about it. I could always try this at a med spa later on when cash is easier to come by :)

3.) Breast Reduction not approved until AFTER 12/13 - or not approved and I have to save up for it. Obviously I will have already had my TT/Panni (possibly with extra lipo). I will do the BR before the pre-cert expires (or in a few years after saving), so another year from now, when I'm as healed as I can be before going under again. Depending on cost of the lipo:
A.) I'm pretty sure that I'll be having the flanks done - if the PS recommends it and it's not cost prohibitive.
B.&C.) if the cost is more than about $1500 extra, I'll save up for it and have it all done when I go in for my BR...