irishmom1972
Member
- Joined
- Sep 21, 2015
- Messages
- 21
Hello Everyone. It's been a while since I last posted here. I wanted to share some great news...My appeal just got approved from BCBS IL for DS. At this point, I'm planning on having surgery in March.
BCBS IL's Medical Policy stated that DS was not medically necessary for patients with a BMI under 50, but their exclusions were arbitrary and certainly was not research based. I received a denial for the DS from BCBS in mid-October because my BMI was 47. I was disappointed but not surprised because I had been aware of their medical policy from the start. So, I immediately began working on an appeal to BCBS. I was advised by former DSers on a FB forum to join Bariatric Facts and contact Diana and Larra. I learned that the whole appeal process could take many rounds over a long period of time. I am so happy that I joined Bariatric Facts and met Diana & Larra. Words cannot express my gratitude for their help and support that they gave me. Between October and January, there were countless emails exchanged, and both Larra and Diana offered their expert advice, and provided me with research articles to strengthen my case showing that DS was indeed very appropriate and has been thoroughly researched in patients who meet NIH criteria for bariatric surgery (not just for patients whose BMI is >50). We went through multiple rounds of revisions on my appeal letter, and each time Larra and Diana would add/edit to make it a powerful appeal. I also obtained LOMNs from my PCP and two bariatric surgeons. Diana actually reached out to one of the bariatric surgeons for me stating that his LOMN would hurt me instead of help the appeal, and she asked him on my behalf to be more supportive of the DS. I was very persistent with the appeal, but honestly I would have been lost without Diana and Larra's help. These ladies are just incredible, and they should really open an insurance appeals business and charge for their services. They're helping people out of the kindness of their own hearts. I don't know anyone else who would do that. They compliment each other so well and work harmoniously. And do they know their stuff and all the insurance tricks that us lay people don't know about. Diana and Larra pointed out things that were vitally important for getting the denial overturned that I would have otherwise inadvertently let go right past me. Diana & Larra provided advice and professional opinions well beyond my appeal letter. They helped me handle numerous interactions with the insurance coordinators at both bariatric offices. I am indebted to these ladies. Their commitment to helping me get approved for the DS surgery was unwavering. I also recognize that during those three months that they were helping me and always seemed to be available, they were also helping countless other people just like me. I'm so blessed to have met Diana & Larra (online) from a former DS patient who happened to hear about my insurance issues and referred me to them.
I finally sent my whole appeal packet to BCBS on Dec. 16. It felt like a load off to get the appeal out the door and in the mail, as I had been working on it with Larra & Diana since October. I then called BCBS at least four times since Dec. 16....twice before Christmas, once last week, and once this week. I learned from past experience that by the time I get something in the mail from BCBS, the date on the document is two weeks behind and the decision had been made at the time as well. When I called this week, I was told that a letter had been generated with the approval to my appeal. I was pumped. I was expecting another denial and another appeal submission, but now I'm actually moving forward with my surgery date and pre-op stuff.
I just wanted to share my experience, and I hope things continue to move in the right direction. As Larra and Diana pointed out, the DS is going to change my life. I'm actually going to start living. If you're fighting insurance battles, keep going. Be persistent and fight for what you deserve. The insurance companies will wear out before you do if you're persistent. Again, a huge heartfelt thanks to two wonderful women, Diana and Larra! They are saints for providing this wonderful, specialized well needed service but asking for nothing in return. That's incredible. Thank you so very much!!!
<mod edit: edited out real name to user name>
BCBS IL's Medical Policy stated that DS was not medically necessary for patients with a BMI under 50, but their exclusions were arbitrary and certainly was not research based. I received a denial for the DS from BCBS in mid-October because my BMI was 47. I was disappointed but not surprised because I had been aware of their medical policy from the start. So, I immediately began working on an appeal to BCBS. I was advised by former DSers on a FB forum to join Bariatric Facts and contact Diana and Larra. I learned that the whole appeal process could take many rounds over a long period of time. I am so happy that I joined Bariatric Facts and met Diana & Larra. Words cannot express my gratitude for their help and support that they gave me. Between October and January, there were countless emails exchanged, and both Larra and Diana offered their expert advice, and provided me with research articles to strengthen my case showing that DS was indeed very appropriate and has been thoroughly researched in patients who meet NIH criteria for bariatric surgery (not just for patients whose BMI is >50). We went through multiple rounds of revisions on my appeal letter, and each time Larra and Diana would add/edit to make it a powerful appeal. I also obtained LOMNs from my PCP and two bariatric surgeons. Diana actually reached out to one of the bariatric surgeons for me stating that his LOMN would hurt me instead of help the appeal, and she asked him on my behalf to be more supportive of the DS. I was very persistent with the appeal, but honestly I would have been lost without Diana and Larra's help. These ladies are just incredible, and they should really open an insurance appeals business and charge for their services. They're helping people out of the kindness of their own hearts. I don't know anyone else who would do that. They compliment each other so well and work harmoniously. And do they know their stuff and all the insurance tricks that us lay people don't know about. Diana and Larra pointed out things that were vitally important for getting the denial overturned that I would have otherwise inadvertently let go right past me. Diana & Larra provided advice and professional opinions well beyond my appeal letter. They helped me handle numerous interactions with the insurance coordinators at both bariatric offices. I am indebted to these ladies. Their commitment to helping me get approved for the DS surgery was unwavering. I also recognize that during those three months that they were helping me and always seemed to be available, they were also helping countless other people just like me. I'm so blessed to have met Diana & Larra (online) from a former DS patient who happened to hear about my insurance issues and referred me to them.
I finally sent my whole appeal packet to BCBS on Dec. 16. It felt like a load off to get the appeal out the door and in the mail, as I had been working on it with Larra & Diana since October. I then called BCBS at least four times since Dec. 16....twice before Christmas, once last week, and once this week. I learned from past experience that by the time I get something in the mail from BCBS, the date on the document is two weeks behind and the decision had been made at the time as well. When I called this week, I was told that a letter had been generated with the approval to my appeal. I was pumped. I was expecting another denial and another appeal submission, but now I'm actually moving forward with my surgery date and pre-op stuff.
I just wanted to share my experience, and I hope things continue to move in the right direction. As Larra and Diana pointed out, the DS is going to change my life. I'm actually going to start living. If you're fighting insurance battles, keep going. Be persistent and fight for what you deserve. The insurance companies will wear out before you do if you're persistent. Again, a huge heartfelt thanks to two wonderful women, Diana and Larra! They are saints for providing this wonderful, specialized well needed service but asking for nothing in return. That's incredible. Thank you so very much!!!
<mod edit: edited out real name to user name>
Last edited by a moderator:
