Submission round 2

[Amey]

Dr Simper's office has sent my paperwork to BC of Idaho today. I'm so scared it will be denied again I don't even dare tell anyone because I don't want to have to explain why it was denied again. This is the only place I feel safe saying anything. And no I didn't get to read the letter they submitted with my paperwork before they sent it. Christina at Dr Simper's office said they use a 'standard' letter for submission. But this time I have the severe obstructive sleep apnea dx and osteoarthritis and Barretts Esophagus to go with my 46 BMI. I'm praying and hoping for the best but prepared for another denial and future appeals. I know I need this surgery and it is the best decision for me. I'm so tired of being obese and fighting to be healthy. If anyone has a spare prayer I could sure use it. Thanks for listening.

 

[southernlady]

Saying prayers and swinging critters!

 

[DianaCox]

You TOLD them you wanted to review it before they submitted! How DARE they ignore your direct order??!

 

[Amey]

Umm yea... Evidently they know more than me because they do this everyday and it's their standard letter with my details on it so I just need to not be confrontational and let them do their job. AND I have never even seen Dr Simper.... I don't know how they can submit without even seeing me as a patient first....but according to Christina they do it all the time for out of state patients. In a way I'm not even expecting an approval but just waiting to be able to start filing appeals. I don't want to get pissy and have another dr fire me... Although that was a good thing after all. I'm tired... And I just want this done and over with so I can get on with my life.

 

[Amey]

@DianaCox Miracles of Miracles! Dr Simper's fax lines were screwy yesterday so my ins paperwork did not get submitted yesterday. I called this morning and she WILL be faxing me a copy of the letter before it is submitted to BC of Idaho. I will post here as soon asxI get it... Stay tuned...

 

[Amey]

@DianaCox..... Christina is going to call me to go over the letter before she sends it so that she can change anything I feel needs addressed. I think this is a great idea instead of just sending it to me and waiting for me make changes and playing phone tag. What do you think? What are the key points I need to make sure addressed and pointed out or quoted?? She will be calling me by 6 pm MST.

 

[DianaCox]

It should include ALL of the points from your PCP letter:

I am requesting precertification for Amey Nelson to perform a duodenal switch procedure (CPT 43845). She has participated in multiple diets, nutrition, and exercise programs (see details below). None of these have resulted in any sustained weight loss. She currently weighs 309 pounds and is 67 inches tall. Her BMI is 48.40.

In the patient’s Blue Cross of Idaho policy it states:

“Under the Exclusions and Limitations section of the member’s policy no benefits can be provided for services, supplies, drugs or other charges that are:
“Z. For weight control or treatment of obesity or morbid obesity, including but not limited to Surgery for obesity, except when Surgery for obesity is 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.””
​

Amey suffers from the following Medical conditions that are eligible for Covered Services under the Policy:​

1. 1. Severe Obstructive Sleep Apnea: this condition can be expected to improve or resolve with substantial weight loss.
   2. Osteoarthritis, with resulting Chronic Pain: this condition can be expected to improve or for progression to be slowed with substantial weight loss; note that this condition will likely require lifelong treatment with NSAIDs, which are contraindicated with RNY gastric bypass.
   3. Esophageal Reflux which has already progressed to Barrett’s Esophagus: this condition can be expected to improve or resolve with substantial weight loss.

Amey has tried to lose weight under my supervision; however the following non-surgical methods have been unsuccessful in treating the obesity:

1. Eliminating processed food and eating whole foods
2. Paleo diet
3. Calorie and carb counting
4. Walking and Weight Lifting
5. Home exercise videos​

All of the above-mentioned Medical conditions are eligible for Covered Services under the Policy, and these nonsurgical methods have been unsuccessful in treating both the obesity and the medical conditions which are comorbidities of her obesity; therefore Amey meets the criteria set by her Blue Cross of Idaho for Medically Necessary Surgery for obesity. I am recommending Duodenal Switch surgery due to the long-term benefits for weight loss and co-morbidity improvement.

Additionally, Amey also meets the requirements of the 1991 NIH Consensus Conference convened to study bariatric surgery which determined that surgical intervention is appropriate in persons with a BMI of 40 or greater.

It is Medically Necessary that Amey receive this surgery as soon as possible in order to correct her potentially life-endangering Medical Conditions. Amey meets the criteria for Blue Cross of Idaho for Medically Necessary surgery for obesity and she meets the NIH requirements.

I am confident you will find Amey Nelson a suitable candidate for the Duodenal Switch surgery procedure. It will assist her in losing weight, as well as maintain that weight loss. I anticipate this will provide her with a significantly improved quality of life as well as significant future savings in medical costs both to Blue Cross of Idaho and for Amey.
​

 

[Amey]

Sounds good I'll let you know how it goes. Thank you again so so very much for all your help. You're an angel!

 

[more2adore]

@DianaCox You are seriously the best.

 

[Amey]

Letter has still not been submitted.... Sigh..

 

[Amey]

Quick update..... Paperwork has still not been submitted to my insurance. Dr Cottam's office did not release the approval/denial for for my band to be removed but not the DS until today... Or at least they said they did. I don't trust anyone in that office and it was a fight to get them to do it. Dr Simper's office sounds like they are talking to my insurance company but they keep telling her that my policy states they will only approve the DS if it's a life or death situation. This is wrong! My policy states Medically Necessary and if I'm already being treated by a covered condition.... Which I am. Dr Simper's office said they are going to deny the request no matter what and I'm going to have to fight them. The surgeon in Blackfoot that is local will be taking appts the first week of September and their insurance person says she gets people with my insurance approved without any problems. She assures me that the dr is experienced with the DS and has been fellowshipped whatever that means but nobody has heard of her. Given the choice I would rather stay close to home. If Dr Simper's office gets another denial and I go to the other surgeon in Blackfoot is that going to make it harder for my insurance since that would be the 3rd surgeon submitting for the surgery? I'm just so frustrated and tired of jumping through hoops. I want this done so I can get on with my life!! I don't know what to do or where to go from here. Help!!

 

[Larra]

It sounds like the new surgeon locally has done a fellowship in laparoscopic surgery, which probably included a lot of bariatric surgery but not necessarily the DS. It's easy for office staff to assure potential customers...oh excuse me I meant patients...that the doctor has done "lots" of some operation or other without even understanding the difference between the various bariatric operations. We also hear many stories of office staff telling people the surgeon does "all" the different operations either out of ignorance of how many operations exist, or being just dishonest enough to get people through the door.
If you decide to have a consult with this new surgeon, that's ok - a consult doesn't commit you to having surgeon with her. If you do this, you should ask very specific, direct questions regarding the DS - how many has she done? Who trained her (since we are talking fellowship, which is an advanced training period, someone had to be training her). Has she done any on her own or just under someone else's supervision? That sort of thing. Then it's up to you to decide if you are satisfied with her level of experience or not.

And if you do this, please let us know what you find out no matter what you decide. We are always on the lookout for new DS surgeons, and it would be great to have one in what is now an unserved location.

 

[newanatomy]

Quick update..... Paperwork has still not been submitted to my insurance. Dr Cottam's office did not release the approval/denial for for my band to be removed but not the DS until today... Or at least they said they did. I don't trust anyone in that office and it was a fight to get them to do it. Dr Simper's office sounds like they are talking to my insurance company but they keep telling her that my policy states they will only approve the DS if it's a life or death situation. This is wrong! My policy states Medically Necessary and if I'm already being treated by a covered condition.... Which I am. Dr Simper's office said they are going to deny the request no matter what and I'm going to have to fight them. The surgeon in Blackfoot that is local will be taking appts the first week of September and their insurance person says she gets people with my insurance approved without any problems. She assures me that the dr is experienced with the DS and has been fellowshipped whatever that means but nobody has heard of her. Given the choice I would rather stay close to home. If Dr Simper's office gets another denial and I go to the other surgeon in Blackfoot is that going to make it harder for my insurance since that would be the 3rd surgeon submitting for the surgery? I'm just so frustrated and tired of jumping through hoops. I want this done so I can get on with my life!! I don't know what to do or where to go from here. Help!!

Does your insurance require a COE (Center of Excellence) designation? If so, I doubt that the hospital in Blackfoot will qualify based on the number of bariatric operations performed per year.

 

[Amey]

I don't see anything in my insurance's paperwork that says Center of Excellence although I believe Dr Simper's office is one. I don't think Blackfoot has that designation. I did a lot of googling today and the new surgeon's fellowship was in trauma. And she had only been doing bariatric surgery for 3 years and has done 3 revisions.... 2 were open. I couldn't find anything where she has done a DS. Sooo ummm I think I'm gonna pass on the new doc. I'm keep pursuing surgery with Simper. I never imagined I would be in for such a circus when I started this to have a revision.

 

[DianaCox]

"Dr Simper's office sounds like they are talking to my insurance company but they keep telling her that my policy states they will only approve the DS if it's a life or death situation. This is wrong! My policy states Medically Necessary and if I'm already being treated by a covered condition.... Which I am. Dr Simper's office said they are going to deny the request no matter what and I'm going to have to fight them."

Did those squnts ever let you review the LOMN before it was submitted? (I'm sorry, I'm helping several people and I get the details confused sometimes.) I would NOT want anyone but Simper himself involved in the appeal process.