Denied on 1st Appeal. Frustrated.

[Mermaid]

Brief background:
2006 Lap Band placed at 242 lbs.
2007 Down to 142
Maintained within 15 lb range for 3 yrs
2010 Weird episodes of too tight, band loosened and refilled
Gained to 170's but maintained in 10 lb range until early 2016
Jan 2016 Band TOO tight. Fluid removed. Pain begins.
March 2016 Nutritionist to "get back on track." Begin tracking food intake
May 2016 Met with Band Doc, continued pain, suspect issue w/band, order tests, discuss nutrition intake
AND DISCUSS REVISION to DS. Order imaging.
June 2016 Met with Band Dr. Discussed continued pain and revision and continued weight gain.
June 2016 Contacted outside DS doc to move to his care. Office asks for a stack of info/testing to be sent or completed.
July 2016 Meet with Nutritionist
July 2016 EGD discovers eroded band in upper stomach
Aug 2016 Nutritionist and separate band removal consult
Sept 2016 surgical band removal (it was not eroded, imaging was wrong, Band doc removed it anyway, did not ask since i was sedated)
Sept, Oct 2016 Nutritionist
Oct 2016 finally met with DS surgeon, Agrees to pursue DS with me. Receives and reviews all records and submits insurance.
Denied!
DS doc calls for peer to peer after sending extra documents.
Peer to peer denied "you cant have a peer to peer after you initiate an appeal"
Nov 2016 1st appeal denied.
"Not medically necessary, no 6 month non-surgical diet that was supervised by the surgeon? WTH?!?!
Their "expert" was a surgical colorectal oncologist. Who is 79 years old! They only listed him as a "surgeon"
The expert said "your doctor is attempting to use this surgery in a way that will not improve your health outcome"

What outcome would not improve?
Replace my band that was removed for a nonexistent erosion (I saw the imaging, it looked bad)?
Help me get my weight and health under control?
Allow me to continue taking meds that I can't take with an RNY?
Replace my crap-band, which is such a faulty device no one is placing them anymore?
What outcome?

I think I hate my insurance right now!

 

[southernlady]

Well, first get a copy of your Evidence of Coverage...it's not the summary but is typically 80-100 pages. If you get insurance thru an employer, your Human Resources dept (or person) can get it to you and you have a right to it. If covered by your spouse thru an employer then your spouse has to get it.

Next, get your copy of the denial letter.

Third, get with @DianaCox and @Larra for help.

 

[DianaCox]

We also need to see the actual written denials, the letter of medical necessity/request for preauthorization that was written by the surgeon, and a full copy of the bariatric policy that applies to your insurance plan. Revision surgery may or may not have a written requirement for a six month diet/exercise plan. We need to see what your appeal rights were in the denial, and in any case, who filed the appeal? You or your surgeon? We can't tell if the peer-to-peer was correctly denied without knowing what was said in the denial letter and the actual plan. Usually, the patient initiates the appeal, but you have to know what you're doing.

 

[Mermaid]

@DianaCox for the record: I have no idea what I'm doing! I do have a giant binder of records and documents. I can put together all the pieces tomorrow and send them to you if you don't mind taking a look. Is there a way to upload or message things to you through here?

I can say the doctors office did the first appeal, I had no idea it should have had input from me. Ignorance seemed like bliss.
I will be starting the letter for a second appeal, but not until I get all the paperwork from the denial decision. I called Anthem customer service today to request all documents associated with the case. They said I should have them in 5-7 days.

I am wondering if there is any recourse with an incorrectly chosen "healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment." I feel like proctological oncology is not the same as a bariatric surgeon. Both are surgeons, but I don't go to a heart surgeon for a brain surgery opinion. Am I crazy that I think this is wrong?

My policy does require "The individual must have serially documented active participation in a non-surgical weight reduction regimen for at least 6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance. These efforts must be fully appraised and documented by the physician requesting authorization for surgery;"

Standard Anthem Bariatric Surgery and Other Treatments for Clinically Severe Obesity SURG.00024

 

[DianaCox]

Well, there is a bigger issue - your bariatric surgery policy is ridiculous, but contains a six month diet requirement for REVISION surgery too: https://www.bcbsga.com/medicalpolicies/policies/mp_pw_a053317.htm

Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss, (that is, unrelated to a surgical complication of a prior procedure) are considered medically necessary when ALL the following criteria are met (A, B and C):​

1. 1. The individual meets ALL the medical necessity criteria for bariatric surgery (see Criteria A thru C) (Note: Meeting the criteria for the initial bariatric surgery does not count toward meeting the criteria again for the repeat surgical procedure for revision or conversion to another surgical procedure.); and
   2. 2 years following the original surgery, weight loss is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight (taken from standard tables for adult weight ranges based on height, body frame, gender and age, an example is available from the National Heart Lung and Blood Institute [NHLBI] at: http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm); and
   3. If inadequate weight loss or regain of initial weight loss following the initial surgery is determined to be due to noncompliance with the previously prescribed postoperative dietary and exercise programs, documentation is required to confirm that a mental health assessment has determined that behavioral issues that resulted in inadequate weight loss or regain, related to noncompliance with postoperative dietary and lifestyle modifications following the initial surgery, have been adequately addressed to significantly mitigate the risk of an inadequate weight loss outcome from the additional surgery.

The only way around this that I see is to argue that "Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss, (that is, unrelated to a surgical complication of a prior procedure) ..." does not apply to you. YOU had a surgical complication of your prior procedure, which resulted in removal of the crapband. You didn't fail the crapband, the crapband failed you.

Grounds for appeal - they applied the wrong revision standard. You do NOT have to comply with A- C to qualify for revision surgery that is related to a surgical complication of a prior procedure; the crapband had to be first unfiled and then removed for medical reasons, and you need a different procedure. The DS is a standard of care procedure which you and your surgeon agree is the best option for you.

That is the angle I would take on the second level appeal; however, in the meantime, you should start working on complying with B: "serially documented active participation in a non-surgical weight reduction regimen for at least 6 continuous months" - see if you can use any of the nutritionist appointments you've already attended, and if your surgeon will use the medical records of those appointments to fulfill this requirement: "These efforts must be fully appraised and documented by the physician requesting authorization for surgery."

Who is your surgeon anyway? The ONLY real DS surgeon in FL is Smith, as far as I know. Stay away from Jawad, who is doing the SADI and not a proper DS, but being very misleading in how he is selling it to patients.

 

[Larra]

The requirements stated seem to apply only in the event of revision in the face of no complication of the original procedure. You had such a serious complication of the original procedure that a bariatric surgeon deemed it necessary to remove the lap band, i.e. to completely undo the original operation. I agree with everything @DianaCox said and I do think you have grounds to appeal this decision. I also wanted to echo what she said about surgeons - we see so much confusion and in some cases outright dishonesty about what procedure is going to be done. I hope you are a patient of Dr. Smith, who has an excellent reputation. If not, your denial may prove to be a well disguised blessing as it gives you a chance to change surgeons. Granted that may slow you up by a couple months, but you will live with the operation for the rest of your life and a small delay, or perhaps needing to travel farther from home, will be well worth it in the very long run.

Please don't submit anything until we've had a chance to go over the relevant paperwork, and if necessary (and it probably is) help you to write a strong appeals letter. Going into this blind doesn't work.

 

[southernlady]

Is there a way to upload or message things to you through here?

To talk to Diana and Larra privately, click on one of their profiles. An overlay will show up and one of the items in the overlay is "start a conversation". You can add the other once you get to that.

As far as documents, they can not be attached in those conversations. Diana once said she will give out her email once you are in private conversation...she still may do that. Other option is to copy the pertinent parts of the EOC and the entire denial letter into the conversation.

Within size limitations, they can be attached in a post to this thread BUT those documents typically contain sensitive information and redacting (covering) parts of it isn't always best as depending on the document format, it can still be read.

 

[Mermaid]

Yes, I am seeing Dr. Smith. I did a bunch of research, I stalked every DS forum on the internet, then picked a well respected doctor in a location I am comfortable traveling to and where there is ample affordable lodging for recovery.

I will be sending full docs to Diana today, but I think I know part of their reason for not considering this a failure revision (The letter with the appeal from Dr. Smith stated that this was a revision due to erosion.)

BUT: There APPEARED to be an erosion. Imaging showed what was thought to be an erosion. The GI doc documented it as an erosion.
The band doc got in there to take it out and...NO EROSION.

Despite pain, fluctuating tolerance of food and repeat band adjustments I believe they are interpreting the NO EROSION only and are blaming my weight gain on me failing the band and not the converse.

ARGH!!!

 

[Spiky Bugger]

@Larra and @DianaCox know this stuff better than I do, but my thinking involves non-linear side trips...so...imho, this is not a revision.

The WAS a previous bariatric surgery.
It was reversed, taken down completely, based on imaging supporting erosion.
NOW...you are, theoretically, back to Square One.
I might try to argue that NONE of the revision criteria apply because there is no longer any previous surgery to undo.

 

[Spiky Bugger]

Also, when an in-house doctor denied my daughter's breast reduction--taking her from a 36J bra to a 36-C because it "wasn't enough"--we reminded them that that FIVE board-certified plastic surgeons who were in their network had all agreed on "how much," but their guy...who per state MedBoard records was an ENT--was odd man out...sooooo...probably a state dept of ins review was needed...they suddenly decided that she was approved.

 

[Larra]

True, it turned out there was no erosion, but even so, a bariatric surgeon familiar with both installing and removing lap bands felt it was necessary to remove yours. To my little mind, that's still a complication of the original procedure. I also agree with @SpikyBugger's argument that there is nothing left to "revise", but I suspect the insurance company will prefer not to accept that argument because let's face it, surgery is expensive and their goal is to spend as little as possible on you, not to make you healthy.
I do think arguing that the reviewer was not qualified in the field of bariatric surgery is a legitimate argument to make, and if it doesn't work with your insurer it may still impress on external review. Which reminds me, you also need to know all your appeals rights, including whether or not you can go to external appeal if/when internal appeals fail. This should also be somewhere in your EOC.

 

[Mermaid]

Nothing left to revise appears to be what they are thinking.
With no "revision" they are seemingly considering this a new surgery, and therefore I need to meet the 6 month diet, psych eval, personal trainer visits...full criteria for a newbie.

And they didn't like what or how the surgeon submitted my 6 month data. Their full denial is based on the 6 month being invalid (for some unclear reason) and a weird comment by a Oncology/Proctologist "your doctor is attempting to use this surgery in a way that will not improve your health outcome"

I called to request the full text of the Appeal Review. "Chris" said 5-7 business days...we'll see.

 

[Munchkin]

List to these folks! They know what they are doing!