"That's right. Two grand for all four of these. If you were to pay "retail", you'd likely have to pay around $45,000-$65,000 in the US. $25-35k for the DS, $8,000 for the tummy tuck, $5-8k for the breast reduction, and $4k for the thighplasty. All of my plastics were inpatient too which means that I remained at least one night in the hospital (two nights for the tummy tuck)."

"I paid a $1500 "co-pay" for my DS and $500 for the thighplasty. Over the course of these procedures, I had three different insurance companies also. It wasn't just because I happened to have one great Magic policy. Additionally, with the exception of the breast reduction, all of the procedures had written exclusions in my various insurance plans."

"So the question is: How did you get your insurance to cover it? I've been asked this question countless times and the few people who have taken my advice in its entirety have all had the same success. It's not a state secret and I didn't pull any magic strings or use connections. Nor did I commit any sort of insurance fraud. I didn't use Photoshop to make myself look more pathetic than I was (as if I could) either. In a way, my profession helped me immensely because as a technical writer, I've learned to document the hell out of anything and I write relatively well. So here are the steps to get your procedure approved:"

": First, you absolutely positively have to do your homework. On your own. This means you don't post to a bunch of forums and bulletin boards asking others what your policy states. Unless someone works for the same company you do, they may not have the same policy even though it's issued by the same company. "

"You cannot rely upon anybody else to tell you what your policy will and will not do for you"

". Argue with me if you want but it's a total waste of time (arguing with me and posting all over the Internet)."

"Read your printed insurance policy and check your insurer's web site for policy bulletins. Read it thoroughly. Does it say "under any circumstances" or is there a codicil somewhere that says "medical necessity"? You also need to determine if your policy is administered by the insurance company or by the company for which you work. This is important because the policies administered by your company tend to be more relaxed with the rules and making exceptions."

"After you read everything you can get your hands on, find out your contacts and keep them all on one sheet. You want to know who you contact at your company as well as the insurance company. Also on this piece of paper, have the contact information (name, address, phone number, and applicable dates) of your WL surgeon, your primary care provider, gynecologist, and every other health care provider you see on any sort of basis. In therapy? Have that information on hand too."

"Now you're ready to get started. I have one word for you and this is the secret to getting your surgeries covered:"

"Armed with the medical prerequisites to have something covered by your policy, you know where to focus your complaints."

"Every time you go to a doctor, bitch and moan and wail and complain. It doesn't matter what you're there for. If you're seeing an MD, any sort of MD...anybody who keeps a record of you, complain. You're laying groundwork and you want it documented. You go to the gynecologist for your annual? Complain about the itching or discomfort of your loose skin. How it's interfering with your daily activities. How it's interfering with your esteem. Married? Bonus. Bitch about how the skin is interfering with your conjugal relations. I'm dead serious. All that skin is preventing your spouse easy access, there is a smell, you're too uncomfortable physically and emotionally, etc. You're getting frequent yeast infections in the skin folds. Here's another big one: It's preventing you from being able to exercise."

"Sometimes they will offer a suggestion. Try this cream, take that pill, do this, try that. If they offer you a prescription, take it and fill it. Use it. Then call and let them know it didn't work. Again, you are laying groundwork, proving that you're exhausting all medical advice to no avail and are providing timely feedback to your doctor."

"You go to your PCP because you have a raisin stuck in your ear? Bitch. You've been to your gynecologist and she gave you this medication for that and it didn't work and you're at wit's end. You're tried homeopathic remedies, this, that. Help me. Do you think plastic surgery would work?"

"Don't ask this too soon. Keep complaining, trying the suggestions (and you have to try them and give the feedback of "it worked a little but..." or "it did nothing"), and leaving messages with your results. Why? Because this goes into your record too."

"...state that skin issues are making you suicidal. This is an immediate red flag and not only will it be noted, your chances of being approved will be drastically reduced because you've now proven yourself to be unstable. You're also giving the impression that you're looking to surgical intervention with unrealistic expectations."

"OK, so you've started your paper trail. You're documenting your physical problems with your doctors, adding a bit of the way it's interfering with the way you live your life. You're documenting your esteem and depression with your shrink. They are keeping these records for you. You're now ready to tackle approval."

"Schedule consultations with your PCP and other providers. Bring a copy of any applicable policy bulletins and explain that you've tried the nonsurgical routes, have done your research, and feel that surgery will alleviate your problem. This is where you tread lightly. You're doing this for medical necessity so you don't discuss the add-ons like lipo or a procedure extending past this barrier...yet. You want them to cover a tummy tuck? Don't approach for a belt lipectomy. Say that you know of these different types of tucks and you feel that this one is the most minimal. Explain you're not doing this for aesthetics, and even throw in the fact that you're reluctant to go back under the knife but you'd rather risk it than continue spending all this money on pointless pills, creams, and remedies."

"You're there for a consultation, not to give a sales pitch. Listen to what your doctor says in response and don't argue...yet. Explain that you looked at your policy and here's what may be required to get it approved. Ask if they agree that you fill these requirements, pointing out how long you've been complaining. Ask if you see a plastic surgeon, would they write a letter of recommendation for you to submit with the paperwork if necessary? Throw in there that you hate what you're turning into, someone always bitching to her doctor and that you need help."

"Do this with every doctor who has been listening to you whine. You may not need them all but before you even see a plastic surgeon, you want to have the backing of these people."

"At this point, you may want to call your insurance company and ask for a list of reconstructive surgeons. Never use the word "cosmetic". This is medical necessity. You may have to give personal information when you call - remember that while you're talking to your insurance provider, they are either recording the call or taking thorough notes. You do the same. When you call, note the date, time, and name of the person to whom you're speaking. Be friendly and never confrontational no matter how difficult they may be. You want them to make nice notes about you. Use the person's name when you speak. "Hi Sara, I'm calling to find out if there is a list of preferred providers for some reconstructive surgery my PCP thinks might help these horrible problems I've been having after losing x pounds". Don't get too detailed about your weight loss just yet for a couple of reasons - first, you don't want to be too pushy and second, you don't know if you're speaking to an obese person and may inadvertently put that person on the defensive."

"Get the information you need and if the person was friendly, encouraging, or helpful, thank her profusely...always using her name. Then ask if you have more questions, would it be possible to contact her directly instead of going through the prompts? You only ask because she was so amazing and kind and you would like to be able to talk to her again."

"A thank-you note faxed over is always a nice touch. So is asking for the name of her supervisor and writing a letter (always better than a phone call because it will go into the rep's file) telling her what a difference she made in this whole frustrating ordeal  and what a joy it was to speak with someone who so very clearly cared and how you're still worried but reassured to discover that there are people like that around."

"Now you go to your surgeon. You know they are on your insurance coverage list so you don't have to worry about this. You have your consultation. You give your history...clinical only. Again, you need to stick with facts and avoid the sob story and avoid the triumphant "I've lost all this weight and now I'm entitled to" attitude. You need help. Please help me. My husband won't have sex with me because the skin repulses him/any sort of sex is painful/I can't exercise/I can't move quickly because the swinging skin weighs down and causes pain. I have these infections/rashes and here's what I've tried."

"Dr. Plastic goes over procedures that might be helpful. Again, keep it low key. You are still looking for basic problem-alleviation only, nothing more. You don't want a breast lift, you want a reduction. You don't want a full tummy tuck, just the skin removal. Thighplasty? Just medial inner, you can deal with the outer...it's the inner that causes the "

".  Remember, you're still focusing on surgical intervention for a medical problem. Nothing more. We'll get to the rest later."

"Your surgeon tells you there's an exclusion or insurance won't cover it. This is where you whip out your policy and explain the medical necessity. Or if it is indeed a written exclusion, you show where medical necessity is discussed elsewhere. You explain that you will do the footwork if they will submit the paperwork. You have the names and contact information of all your providers and will work with their insurance person to get it filed."

"After your consultation but before the
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