Crap band removal approved but DS denied.... Help!

[Amey]

Has anyone had any success appealing a denial with Blue Cross? I was approved to have my lap band removed but denied the revision because they say it's not medically necessary. I have a BMI of 47 but no diagnosed comorbidities. I know I have sleep apnea but it's never been diagnosed.... And I have to get a sleep study pre-authorized by ins then wait another 2 wks for results. But I only have a small window to appeal. The surgeons office is going to set up a phone conference with the insurance's dr that makes the decisions and Dr Cottam but that could also take a couple weeks. Having my crap band removed is a life is life threatening at this point due to my Barrets Esophagus. My knees are killing me... I can barely walk up the stairs at night and my hips hurt to walk around the block. I'm feeling so discouraged and defeated right now. A few very nice ladies in a couple of DS Facebook support pages sent me here and told me to ask @DianaCox or @Larra for help. I'm begging and pleading!! Any help would be greatly appreciated. I just got the denial letter and Evidence of Coverage document emailed to me.... Just let me know what you need. I will do anything!!! Thank you so much!!

 

[robs477]

@Amey,

You are SO fortunate, as are we all. You have found the right place! Those two Angels and many others here have helped countless #’s of people, myself included. READ EVERYTHING THAT YOU POSSIBLY CAN from old posts and learn and they will be responding very quickly as soon as they see your post. Your situation sounds very solvable and I give you my best wishes and a warm welcome to our home.

 

[Amey]

@Amey,

You are SO fortunate, as are we all. You have found the right place! Those two Angels and many others here have helped countless #’s of people, myself included. READ EVERYTHING THAT YOU POSSIBLY CAN from old posts and learn and they will be responding very quickly as soon as they see your post. Your situation sounds very solvable and I give you my best wishes and a warm welcome to our home.

 

[DianaCox]

That makes no sense to me at all - unless YOUR insurance policy requires a comorbidity even with a BMI of 47, which I haven't seen with BCBS before (but individual plans can differ, especially if they are self-funded plans). NIH guidelines say that a BMI of 40 is the definition of medically necessary morbid obesity. You need to check your bariatric policy. It may be that this is one of those plans that says the DS isn't medically necessary unless your BMI is >50 - we have helped people appeal and win on that basis for denial many times.

@Larra and I would need to see your actual denial to understand better what the basis for the denial was. But in the meantime, you can file your appeal - call it a NOTICE of appeal - and state that you need time to have your sleep apnea test - on the last day. When is the last day.

 

[Amey]

My ins policy says bariatric surgery is excluded unless medically necessary but doesn't really say what they consider medically necessary, if I am reading it correctly. It is not a self funded plan... It is through the state exchange. When I lost my job I had to go on the exchange to get insurance. I called the bariatric center locally to find out which ins I needed to cover the surgery. This is the one that the insurance coordinator told me they have never had a problem with as long as I meet guidelines for medical necessity.... Which according to her I do.....she works with this ins every day - However, Dr Cottam's office doesn't as I my ins is Blue Cross of Idaho and Dr Cottam is in Utah so they have little to no experience with my insurance company. I didn't have surgery through the local facility because their surgeon at the time only did sleeves. I know I need a power drill not a screw driver so a sleeve would be as much good as this crap band... That surgeon referred me to Dr Cottam in Salt Lake. The local surgeon's secretary had a DS by Dr Cottom last week - he came very highly recommended and has excellent reviews . However, his staff and especially his ins processor is known for being rude and not returning phone calls or answering they phone.... You have to go through a secretary or her boss to get anything done. I have the letter of denial... It just says that Dr Cottams documentation did not prove medical necessity. Nothing more... Nothing less. I will attach a copy of the letter and the insurance coverage document here.
I also was able to get the surgeon that operated on my knee a few years ago to send his notes stating I have arthritis in my knees to Dr Cottam's office. Don't know if that will help or not.
Dr Cottam's office is going to try to set up a peer to peer phone conference. But the office manager that I talked to about it said that they aren't very successful and not to get my hopes up. He said I could do a sleep study if I wanted but it probably wouldn't do any good if I couldn't get results before they did the peer to peer, which I probably won't since the sleep study has to be pre-approved by insurance and then will take 2 weeks for results.
I'm not sure how long I have for the appeal - the denial letter states that the approval to remove my lap band is only good for one day, July 31st, which is stupid because my surgeon doesn't even do surgery on that day and I could have the stupid thing yanked out in Idaho without driving 4 hours one way if that's all I was going to do. UGH I'm so frustrated!!!!!
So where do I start? Where do I go from here?
And thank you for answering my call for help. I felt like I was sending up the bat signal lol.

 

[DianaCox]

[There is something funky with the bolding - it won't post the way I wrote it.]

OK, this is what's in your policy under Exclusions and Limitations:

"For weight control or treatment of obesity or morbid obesity, including by not limited to Surgery for obesity, except when Surgery for obesity is [a] Medically Necessary to control other medical conditions that are eligible for Covered Services under the Policy, and nonsurgical methods have been unsuccessful in treating the obesity. For [c] reversals or revisions of Surgery for obesity except when required to correct an immediately life-endangering condition."

​

So, your denial is for one or MORE of these reasons:

• [a] They are REQUIRING that you have a comorbidity ("medical condition") to be treated that would be alleviated by bariatric surgery, and Cottam did not demonstrate that you have one - or did not use the right language to assert it.
  • Ask Cottam to provide you with his letter AND ATTACHED DOCUMENTATION that he submitted to your insurance requesting preauthorization - it is highly likely that he screwed it up, and we need to know what is missing or wrong.
  • Unless Cottam failed to provide documentation of your BMI, it appears you need to submit additional information.
    
  • What documentation DO you have of your comorbidities? Medical records documenting:
    • Sleep apnea
      • This should be the easiest one to prove
    • Osteoarthritis
    • Hypercholesterolemia/hyperlipidemia
    • Type 2 Diabetes
    • Hypertension
  • This requirement is outside of the NIH standard of care for medical necessity for treatment of morbid obesity, which does not require ANY comorbidities for BMI >40 - that is one ground of appeal
• What proof of prior nonsurgical methods [which] have been unsuccessful in treating the obesity were submitted with the request for precertification?
  • I'm guessing none, because Cottam's office sucks and they don't care
  • Cottam should have at least submitted any pre-lapband diets that you tried and failed.
  • Cottam should also have added that despite meticulous compliance with the diet and exercise instructions you were given with your Crapband, you failed that too, indicating your need for a more effective metabolic surgery than you were offered in the first place.
• [c] In other words, it appears you have a one-surgery-per-lifetime exclusion, and that's what they are alleging.

I don't see any evidence that BCBS provided the required appeal information, including telling you how long you have to appeal. Were do you get the idea that your time to appeal will run out before you can get a sleep apnea test? Are you thinking the July 31st date means something? It really does not - they can't tell you what day to have surgery! What if the doctor is unavailable? What if you had a conflict that could not be rescheduled? You will simply ask for your approval for the Crapband removal to be extended until you complete your appeal of the DS, to avoid the necessity of undergoing two separate procedures, anesthesias, hospitalizations, etc., as well as recoveries, which will save both you and BCBS money. And you will ask for expedited approval of the sleep apnea study.

Stop panicking. And stop assuming Cottam's office (or Cottam himself) knows how to submit for insurance approval properly, or cares (they have an ENDLESS pipeline of MO patients. DEMAND COPIES OF ALL OF YOUR RECORDS, including his submissions - we need to see what he did wrong.

Oh, and is he trying to talk you into a SADI/SIPS/loopDS? If I were you, I'd be DEMANDING a proper DS, and be prepared to fight him for the full monty - you are a revision, and need more metabolic effect and more malabsorption.

 

[Amey]

I just looked at my paperwork...and sure enough the consent paper I signed says LOOP DS - how did I miss that?? I definitely want the REAL DS - not the Frankenstein version. How do I get that changed? The pre-authorization he sent in said it was just for the DS.....so I'm confused. Is he doing the DS or Loop??

Either way....I have the paperwork his office submitted to BC of Idaho. I will scan it at work tomorrow and attach it here. It seems like it's a form letter with things like he/she and not my name or SHE in the letter....It's pretty choppy...but what do I know about insurance and doctors. Sorry, I don't have a scanner at home or I would send it tonight. It does say what my BMI is and that I meet NIH standards and that I have muskuloskelatal disease.....which I guess just means aching joints. He states that it is a life or death situation to have my band removed due to my Barrett's Esophagus. I'm guessing that's why they approved that. In fact the office had to send that page twice because the insurance company 'missed that part' so Cottam's office had to send it again and circle it with a black sharpie. UGH!!

And yes...I assumed the July 31st date was the only date I could have my band removed and the last day to appeal. I don't want to have my band removed without the revision. Yes...it needs to come out IMMEDIATELY but I would gain 100 pounds without what little restriction I do have. My band is horrible....my port is like a rock in my ribs, I can't bend over, the acid reflux keeps me up at night even with 40 mg of omeprazole a day...I have days where I can barely swallow my own spit and then the next day I could eat my way through a grocery store and I am NEVER NOT HUNGRY. I'm just waiting for the class action suit against the band. What the hell were we all thinking that a foreign object wrapped around our stomach would be a good thing??

So how does this work? Do I write a letter to the insurance company or to Dr Cottam's for them the submit to the insurance company? Should I do it before they have their peer to peer thing or after? And what would I say exactly in the letter? I'm horrible at things like that...I tend to get personal and whiny and ramble (if you can't tell). Do you coach me in the appeal or do you talk to the insurance company or surgeon's office?

And here is another thing.....the original surgeon's clinic that is local that referred me to Dr Cottam.....their surgeon's last day was today. Evidently they are bringing in 2 new surgeons, a man and a woman, that specialize in high risk band removals and will do the DS. But their insurance coordinator (who seriously deserves a dozen roses for helping me so much through all this) can't give me names. They won't be starting until between Aug 1 and 15th. And she doesn't know when they will be starting to do surgery and I imagine they are going to have a back-log. It would be nice to be closer to home (30 minutes) vs 4 hours to Dr Cottam's office. And I LOVE the staff that is local.,....even though I'm not an official patient they have helped me and answered my questions and always takes my phone calls. So.....I have no idea who these doctors are....and honestly this is a really small town and the hospital has no ICU to speak of....I have to wonder what caliber of doctor would want to go there. But Cottam's office is starting to make me nervous....I don't have a real great feeling about them right now. Is there a way to change the doctor after I know more about who is coming to our local hospital? And...since my band being removed is life threatening .....if I wait that long will the insurance company completely deny everything because I didn't act on getting my band out sooner?

I am trying to breathe....I am trying to calm my ass down....I'm going to go take a hot bath and try to get some sleep. I will scan and email the letter before noon tomorrow.

Thank you again for all your help.....I feel a lot better than I did this morning. You are awesome!!!!

 

[DianaCox]

Yeah, we need to know who the new surgeons are - you don't just start doing them, and ID is a small place to set up that kind of practice. I'm suspicious.

If you can go out of state, I would URGE you to look into whether you can use Dr. Keshishian in Glendale CA, or Dr. Rabkin in San Francisco.

In the meantime, you need to have a conversation with Dr. Cottam ASAP asking him if he will do a PROPER DS if you insist on it. If he says no - there's your answer. Your approval for the band removal should be good anywhere that is in-network.

Life or death doesn't mean it has to be done next week - Barrett's can become esophageal cancer, but it is unlikely to matter whether you get the band out next week or in the next couple of months.

Before you bother with Cottam having the peer review, you need to get clear with him that you ONLY want a full DS with BOTH anastomoses, and a common channel no longer than 125 cm, preferably 100. If he won't agree, there's no point in letting him f up your appeal. Find out the answer to that question FIRST. Then we'll figure out how to prepare the appeal, including how to get it with someone else if necessary.

And find out about the new surgeons. You not only want to know about their DS qualifications, but whether they will do the band explantation in the same surgery with the DS. We know for a FACT that Dr. Keshishian can and will do it almost every time. @Larra and I have guides for writing an appeal, but you need to track down some of your old records about pre-op diet, exercise and nutritional consults before your Crapband so we can say you meet those requirements - it may take a couple of weeks for you to get copies from your former docs.

 

[Amey]

I am attaching the consent that I signed and the paperwork that Cottam's office sent to BC of Idaho. I talked to the insurance coordinator at Bingham Memorial Hospital (the local clinic) and the two doctors coming in are....drum roll.....Adam Goldenberg (will be there mid August) and Lisa Medvetz (will be there mid September). They are both coming from the East coast....she thought it was the Pennsylvania area. Do you know anything about these doctors? They are about 20 patients backed up ready for surgery but they will be jumping in when they get there.

I thought about this a lot last night and whether it's my emotions or what I don't know...but I just get a really uneasy feeling about Cottam. I REALLY do not trust that he had me sign one thing and submitted something else to insurance - whether that was his staff's error or his I don't know. But his staff is worthless and doesn't care. I know Bingham Memorial cares - even if they are a lot smaller. I think I would just feel better if I could put the brakes on everything until I can get the sleep study done and another doctor to verify arthritis in my knees and I'm sure I have it in my hips too. I don't want Cottam's office screwing up anything else!!!!! Especially not my body!!!!

I would love to be able to go out of state to Dr Keshishian but unfortunately I can't afford to go to California and I don't have any family that could take the time off work to go that far with me.

I can get the copies of all my notes from the crap band and surgical reports from the New U clinic at Eastern Idaho Regional Medical Center where I had it done. It's about 70 pages. Can I upload that much here or would it be better to fax or email that to you directly?

Sooo.....how do I put the brakes on the insurance appeal and fire Dr Cottam? Is that even possible at this point? Or do I have to let Cottam do the appeal since he started it? I'm so glad I found you and you know how to jump through these flaming hoops. I'm not afraid to walk over hot coals....I just want to know what's on the other side.

Just let me know what I need to do....I haven't called the insurance company yet but I'm going to call Cottam's office and at least tell them to hold off on the peer to peer.

I am attaching 2 documents. I will wait for your response and further instructions.

.....I feel a lot better than yesterday....THANK YOU!!!!!

 

[southernlady]

I can get the copies of all my notes from the crap band and surgical reports from the New U clinic at Eastern Idaho Regional Medical Center where I had it done. It's about 70 pages. Can I upload that much here or would it be better to fax or email that to you directly?

While we do have the ability to upload, I think that exceeds the limit.

 

[Amey]

That's what I thought. Hopefully @DianaCox will have another suggestion.

 

[Larra]

Hi and welcome!
I will try to catch up later today when I have a chance. Meanwhile, take a few deep breaths, slow down, and let's get this mess sorted out.

I will say regarding Dr. Cottam that he has the reputation for being technically good, so that's a plus, but he's apparently gone completely to the loop or SADI or SIPS or whatever he's calling it, which IMHO is not good. Long term results are unknown, and I think esp for someone who has already had one bariatric operation fail, the last thing you want is something unproven. I agree with Diana that it's time for a conversation directly with him - NOT anyone on his staff - asking whether or not he is willing to do the full DS for you. If he says, no, you have your answer and you know you need to move on.

And it is disturbing that you came away from your consultation not realizing that he was planning the loop DS for you and not the full DS. His specific plan should have been made crystal clear with a full discussion of your options. Of course I wasn't there, I don't know what he said or didn't say, but you came away without understanding what was planned, and that shouldn't have happened.

 

[Amey]

Sleep study is tonight. Yayyyy!

 

[DianaCox]

Sorry, I've been busy today.

Demand to speak to Cottam directly. If he won't speak to you, you have your answer. If he does speak to you, ask him straight up why he put the LoopDS on your consent, and (1) submitted for the DS (he's going to say "it's the same thing"), and then (2) why he didn't make it clear to you, when you said you were seeing him for a DS, that he had no intention of giving you one - because you are a reasonably well-educated patient, but sure as SHIT did not give informed consent to an experimental procedure, and if it had not been pointed out to you on the message boards, you would have been DECEIVED into having a procedure that was NOT what you wanted, NOT what you requested, and NOT what you give informed consent for. You will have your answer about whether you want to use him when he answers those questions.

I note that the SINGLE reference to LoopDS is it the title of the document, and the description itself does NOT specify LoopDS - in fact, it appears to me that it is describing a PROPER DS:

* The Malabsorptive Component
The malabsorptive component of the DS procedure rearranges the small intestine to separate the
flow of food from the flow of bile and pancreatic juices. This inhibits the absorption of calories
and some nutrients. Further down the digestive tract, these divided intestinal paths are rejoined;
food and digestive juices begin to mix, and limited fat absorption occurs in the common tract as
the food continues on its path toward the large intestine.​

The loopDS doesn't separate food from the flow of bile and pancreatic juices - the food leaves the stomach and IMMEDIATELY contacts bile and pancreatic juices - but in a shortened alimentary tract. The loopDS doesn't have two "divided intestinal paths" - it has one path.

Having said that, and advising you to do and say things that will probably burn your bridges with Cottam, I've never heard of the two surgeons coming to your area.

Regarding Goldenberg: he joined Nazareth Hospital in Philly in December 2014 - "relaunching" their bariatric program - yet he's already leaving to move to (pardon me for saying this) BFE Idaho? http://www.mercyhealth.org/about/ne...-lose-weight-in-2015--attend-nazareth-hospit/

"Nazareth Hospital has relaunched its bariatrics program with the addition of Mercy Bariatrics surgeon E. Adam Goldenberg, MD, to its medical staff. A graduate of Ponce School of Medicine, Dr. Goldenberg completed his graduate medical training at New York Hospital Queens and a fellowship in endoscopic and laparoscopic surgery at the Emory University Endoscopic Unit in Atlanta, as well as a bariatric surgery fellowship at the University of Pittsburgh. Dr. Goldenberg is board certified and specializes in laparoscopic bariatric surgery."​

None of those hospitals have DS practices.

Regarding Medvetz: http://www.lmanet.com/Medvetz.html

"Dr. Lisa A. Medvetz is the director of the bariatric and metabolic surgery program at Lourdes Medical Center of Burlington County. As a general and bariatric surgeon with over ten years' experience, she finds great reward in helping and supporting her patients through their medical journeys and seeing them achieve greater personal and physical health. Dr. Medvetz specializes in advanced bariatric procedures, including laparoscopic/open Roux-en-Y gastric bypass, laparoscopic adjustable gastric band, laparoscopic sleeve gastrectomy and revisional surgery, particularly the conversion of Lap Bands to sleeve gastrectomy or gastric bypass."​

There is NO evidence that either of them does the DS.

 

[DianaCox]

Oh, and if you think that Cottam has screwed up your request for DS, you CAN start over again with another surgeon. But since you're getting the sleep study done tonight, I'd let him do the peer to peer. If you get approved, then you can take your approval to another surgeon. If not, you can start over with another surgeon.

You do know that there used to be a DS surgeon in Idaho, right (but I don't see that he's still practicing):
St. Luke's Metabolic and Bariatric Surgery Clinic
333 North 1st Street, Suite 120
Boise, ID 83702
Phone: 208-381-7190

http://www.stlukesonline.org/boise/specialties_and_services/Bariatric_Surgery/index.php
But this site doesn't include Oakley as a doctor in that practice anymore. Perhaps you can track him down?