MamaShelia
Well-Known Member
- Joined
- Oct 4, 2014
- Messages
- 73
Hello ALL!
I haven't posted in almost exactly 2 months and a lot has happened in life! I will spare you all of it (a death in family, I lost a teacher on my team to depression--she just walked out of the building--and have been covering her classes as well as my own, I had a lupus crisis in November, and now I have had an allergic reaction to no one knows what, but I do so need to update you all before more time passes!)
Oct 7th: I had consult with Dr. Ayoola in TX. I have selected him as my surgeon for my revision to DS. I was very impressed with his knowledge base and bedside manner. I asked all types of questions about previous cases, how many DS's he had performed (too numerous to count) how many RNY to DS revisions --5!
Whoa, Nellie, did you say, 5?!?
Well, yes, Nellie, he did.
After much consideration and prayer my husband and I felt that we had rapport with him and that every surgeon on the preferred list had a patient who was their number SIX in order to get to the hundreds of patients that they have under their belts and we are willing to be his number 6. (I am driving 7.5 hours to get to AYOOLA)
So we are sticking with Dr. Ayoola.
So on OCT 9th, I had an EGD with him and he did not find a "mini bypass" but he did find that the limbs were not the lengths that original surgeon had described in the preoperative notes. I can't remember right now, but the one that Ayoola usually leaves a little longer, mine has been trimmed pretty short and the limb that he would have trimmed shorter was left longer. (Will get back to you....don't have my folder in front of me.)
Ayoola sent me home to get clearance from my cardiologist. I had a scheduled apt with him on Oct 23rd anyway and we scheduled a stress test for Nov 11th.
Got the results and the letter of clearance to Dr. A's office on Thanksgiving Monday and we are rolling right along.
Dr. A's staff sent in a pre certification request, CIGNA sent it back for more info...which we all had on file already (not sure why they didn't turn it all in art once) anyhow....all of our cards are on the table and I just got an email from AYOOLA's office manager tonight that he had received a letter of DENIAL...okay...poopy news, but expected, so...I am over it.
Actually I had called on Friday afternoon and found out and the person on the phone pulled the record for me, because a determination had not been posted yet and she told me I was denied for two reasons 1. I did not have proof of 90 days of nutritional/weight loss visits and 2. my BMI was less than 50 (I am at 45), she sounded very positive and said as soon as you complete your 90 days, the one will be taken care of and your doctor can call and speak directly to the medical reviewer and the other will be taken care of.
OKAY, back to today, when the office mgr emailed me about the denial, he said the letter states that I have not proven 2 years of compliance to the original post op diet, well there is NO WAY to do that. I saw Dr. Olchowski ONCE after my surgery for a 1week follow up and that is IT. He never required any more visits and now that he has lost his license, even that one visit cannot be retrieved.
So, QUESTION: How do I get CIGNA to understand that nothing from that time is able to be retrieved?
ANOTHER QUESTION: Was the CIGNA REP who answered the phone on Friday and read the reviewer's notes getting confused with 90 days of nut visits and 2 year's compliance, or have you guys seen cases where the 90 days can fill in for the 2 yrs post op if medical necessity is proven?
Office manager asked if I wanted to appeal, I said most definitely. Especially if all I need is 90 days nut (I am going to call CIGNA tomorrow and see which it is 90 days or 2 yrs post op to be sure, that side of the insurance office not open on weekends) and then a call from Dr. Ayoola to call in. Yes, I want to appeal!
NOW, THIRD QUESTION, when do I need to send in articles for BMIs under 50 can be just as successful with DS and letter from me and my personal circumstances and all of that?
Do, I do that through Dr. Ayoola's team or on my own?
Thanks for reading...any and all replies welcome!
Hugs,
Shelia
I haven't posted in almost exactly 2 months and a lot has happened in life! I will spare you all of it (a death in family, I lost a teacher on my team to depression--she just walked out of the building--and have been covering her classes as well as my own, I had a lupus crisis in November, and now I have had an allergic reaction to no one knows what, but I do so need to update you all before more time passes!)
Oct 7th: I had consult with Dr. Ayoola in TX. I have selected him as my surgeon for my revision to DS. I was very impressed with his knowledge base and bedside manner. I asked all types of questions about previous cases, how many DS's he had performed (too numerous to count) how many RNY to DS revisions --5!
Whoa, Nellie, did you say, 5?!?
Well, yes, Nellie, he did.
After much consideration and prayer my husband and I felt that we had rapport with him and that every surgeon on the preferred list had a patient who was their number SIX in order to get to the hundreds of patients that they have under their belts and we are willing to be his number 6. (I am driving 7.5 hours to get to AYOOLA)
So we are sticking with Dr. Ayoola.
So on OCT 9th, I had an EGD with him and he did not find a "mini bypass" but he did find that the limbs were not the lengths that original surgeon had described in the preoperative notes. I can't remember right now, but the one that Ayoola usually leaves a little longer, mine has been trimmed pretty short and the limb that he would have trimmed shorter was left longer. (Will get back to you....don't have my folder in front of me.)
Ayoola sent me home to get clearance from my cardiologist. I had a scheduled apt with him on Oct 23rd anyway and we scheduled a stress test for Nov 11th.
Got the results and the letter of clearance to Dr. A's office on Thanksgiving Monday and we are rolling right along.
Dr. A's staff sent in a pre certification request, CIGNA sent it back for more info...which we all had on file already (not sure why they didn't turn it all in art once) anyhow....all of our cards are on the table and I just got an email from AYOOLA's office manager tonight that he had received a letter of DENIAL...okay...poopy news, but expected, so...I am over it.
Actually I had called on Friday afternoon and found out and the person on the phone pulled the record for me, because a determination had not been posted yet and she told me I was denied for two reasons 1. I did not have proof of 90 days of nutritional/weight loss visits and 2. my BMI was less than 50 (I am at 45), she sounded very positive and said as soon as you complete your 90 days, the one will be taken care of and your doctor can call and speak directly to the medical reviewer and the other will be taken care of.
OKAY, back to today, when the office mgr emailed me about the denial, he said the letter states that I have not proven 2 years of compliance to the original post op diet, well there is NO WAY to do that. I saw Dr. Olchowski ONCE after my surgery for a 1week follow up and that is IT. He never required any more visits and now that he has lost his license, even that one visit cannot be retrieved.
So, QUESTION: How do I get CIGNA to understand that nothing from that time is able to be retrieved?
ANOTHER QUESTION: Was the CIGNA REP who answered the phone on Friday and read the reviewer's notes getting confused with 90 days of nut visits and 2 year's compliance, or have you guys seen cases where the 90 days can fill in for the 2 yrs post op if medical necessity is proven?
Office manager asked if I wanted to appeal, I said most definitely. Especially if all I need is 90 days nut (I am going to call CIGNA tomorrow and see which it is 90 days or 2 yrs post op to be sure, that side of the insurance office not open on weekends) and then a call from Dr. Ayoola to call in. Yes, I want to appeal!
NOW, THIRD QUESTION, when do I need to send in articles for BMIs under 50 can be just as successful with DS and letter from me and my personal circumstances and all of that?
Do, I do that through Dr. Ayoola's team or on my own?
Thanks for reading...any and all replies welcome!
Hugs,
Shelia
