RNY to DS revision denied- Helpful advice needed

[Trilla]

Hi all

1st thanks everyone for the support and all the helpful information in here. I started in here looking for a surgeon to perform a revision for me in IL- that has since changed.

INFO
- I am 5'6", 290lbs, BMI 46.8, insurance BCBS of IL, was 345lb in 2005 and had RNY, lost ~120lbs, for various reasons i am in continuous pain and have slowly gained to my current weight.

I decided that DS is the best option for my success. I chose Dr. Ayoola in TX to perform the revision. They sent off my to insurance and I have "not been approved"...

"Requested service(s) does/do not meet medical policy criteria/guidelines for coverage...

Deny 43659 (Lap Duodenal Switch) Medical Policy: Bariatric Surgery (SUR716.003) considers this service not medically necessary because your BMI is below 50. Also your medical records shows you had a gastric bypass in 2005, so this procedure would be considered a revision (re-do) surgery. This policy considers this service not medically necssary because you have not followed the prescribed nutritional program following the original (first) surgery.... EGD is showing technical failure.

Your physician may contact the Health Care Management Department to discuss this case with a physician adviser."

I contacted Dr Ayoola's office and they set up a meeting with this physician adviser this Friday. I was told there might be a chance that I could get the surgery, that its all up to the doctors on the call.

Besides gaining 20 lbs that would put my BMI to 50.... I want to provide additional information to Dr. Ayoola and/or BCBS to help my case. I have only spoken to Dr. Ayoola once. Right now I'm just a bunch of tests results to them.

I want to write a letter to Dr. Ayoola so he has more information about me and my weight experiences. Something that would help change the mind of the BCBS doctor. What should I write? What can I do? They factored in that there was a technical failure and still denied.

Have any of you succeeded in getting an approval after a denial from BCBS of IL with a revision from RNY to DS with Dr. Ayoola?

 

[Trilla]

I found the link with lots of useful information in the Insurance forum.

But it still would be nice to know if other folks have been successful and how they did it.

Thanks

 

[DianaCox]

I don't know if anyone else met all 4 of those things at the same time, but yeah. All of those have been dealt with.

"because you have not followed the prescribed nutritional program following the original (first) surgery.... EGD is showing technical failure."

Well, which is it? What is THEIR proof that you didn't follow the "prescribed nutritional program?" Are you prepared to rebut that? Is it in your medical records? You need to find out why they are saying this.

Nevertheless, they ADMIT that there is a technical failure - so what's up with that?

 

[Trilla]

Nevertheless, they ADMIT that there is a technical failure - so what's up with that?

When I was being told that I was denied after the peer to peer, I asked about that. I was simply told that it was a "technical failure with non compliance." I don't know if i will get a letter with a full explanation of the peer to peer outcome. I was only told in an email by the doctor's office on Friday.

It appears that technical failures don't matter when they deem I haven't been compliance since I gained weight after my RNY. which is peculiar.

Which makes me think that the insurance company is just denying to see if i will give up to save them the $. At this time I only have to $1.5k left to pay until they pay 100%. call me suspicious, but I think if they approve, it will be after the new year when my insurance out of pocket resets.

I wrote my full experience thus far in the Insurance section asking for help.

Thanks

 

[Battenabrowngold]

I don’t have BCBS of IL, but I do have BCBS of NC. I was denied for “non-compliance” three or four times. I went through the entire appeals process. The last shot I had was to appeal through the NC dept of Insurance who hires out a third party called MPRO (Michigan Peer Review Organization) and they decided to overturn my denial based on my EGD results which showed an extended pouch. The whole process took a year and honestly I was super surprised they chose to overturn the denial. I wish I had magic words for you. All I can suggest is to keep appealing it and use every avenue you have - such as the final external review option if that is allowed in your state. BCBS is the worst at approving revisions according to my surgeons office.

Good luck!

Amber

 

[Trilla]

I saw some businesses that specialize in helping people with WLS appeals.

So far I have been denied twice (1. original request, 2. peer to peer). can you tell me how many times you were denied and at what stage? how long did it take for them to get back to you with each denial and then the final approval?

My doctor (Dr. Ayoola) wrote a great appeal letter with documentation i provided him. he included research studies and other supporting information. The appeal was submitted 2 weeks ago and the insurance company has up to 30 business days (6 weeks- 4 weeks left) to give their decision. I really hope they approve it.

 

[DianaCox]

If they don’t, Larra and I can help you file a request for Independent/External Medical Review.

 

[Battenabrowngold]

I saw some businesses that specialize in helping people with WLS appeals.

So far I have been denied twice (1. original request, 2. peer to peer). can you tell me how many times you were denied and at what stage? how long did it take for them to get back to you with each denial and then the final approval?

My doctor (Dr. Ayoola) wrote a great appeal letter with documentation i provided him. he included research studies and other supporting information. The appeal was submitted 2 weeks ago and the insurance company has up to 30 business days (6 weeks- 4 weeks left) to give their decision. I really hope they approve it.

I was denied four times I believe. Three of those times, letters were just sent with more information each time. Then, the fourth time (could have been the third time, I really don't remember), I had a phone conference with an external doctor who was just a surgeon that the insurance company pays. In addition to what was already submitted on my behalf, I read a letter I had personally written and my surgical coordinator at my surgeon's office also said quite a few words - mainly about how obesity is a disease and like other diseases, sometimes need to be treated multiple times. That surgeon (who was not a bariatric surgeon) denied me, too. The last stage was the appeal to the NC Department of Insurance who hires out MPRO as an external reviewer where an actual bariatric surgeon reviewed my case and overturned BCBSNC's denial and BCBSNC didn't fight it.

I hope that helps. I can't remember if I was denied two times and then had the phone conference with a live human being or if I was denied three times and then had the phone conference. The whole process took about a year.