Need some help- Request for DS Revision Denied

Trilla

Member
Joined
Jul 22, 2018
Messages
19
@DianaCox @Larra

From the other forum....
1) You need to have a hard copy of your Evidence of Coverage. NOT the generic policy that an insurance company puts out but the one that applies to JUST YOU.
I have this

2) IF you have been denied, have a copy of the letter handy so you can tell people WHY it was denied.
I have this

3) Be prepared to bare your entire medical history to the two people who help others get their surgery. Be advised that you will need to be very open about your present situation, medical history and such, because there is no way a strong case for the medical necessity for a DS or a revision without knowing quite a bit about you.
That’s fine

My History
Aug 2005
RNY surgery. Weighed 345lbs, severe sleep apnea.

Aug 2010 Lost 115lbs.

< I requested all my medical claims from insurance for procedures, dates and doctors. I will fill out a history.

It is important to note that I was doing fine until I was in a car accident. I've been in constant pain especially when I put weight on it). I had 2 surgeries on my foot, (planning on a third), a number of steroid injections, physical therapy, chiropractic care, fit for orthopedics, iron infusions, b12 shots…list goes on >

April 17 Annual exam with my GP

April 18 Consultation with Dr. Joyce at Bariatric & Minimally Invasive Surgery (BMI)

May 10 Endoscopy (determined my stoma was enlarged- I don’t know by how much)

May 16 Pulmonary appointment

May 17 Cardiologist (fine)

May 17 Consultation with Dr. Joyce. Told me my only option was band over bypass

May 17 1st weigh in & nutrition meeting

May 22 Sleep study (moderate sleep apnea)

June 20 2nd weigh in & nutrition meeting (Nurse)

July 15? Decided I wasn’t comfortable with the band over bypass option. Researched revision surgery. Chose Dr. Ayoola in Texas.

July 23 3rd weigh in & nutrition meeting (Nurse)

Aug 9 Dr. Ayoola consultation

Aug 17 Yajaira (Dr. Ayoola’s Practice Manager/Insurance POC) confirms they have all my paperwork

Aug ? was approved for the band over bypass procedure at Dr. Joyce’s office

Aug 21 Nutritionist Consultation with Dr. Ayoola’s office (Sandy Weatherly, RD, LDN)

Aug 24 Dr. Ayoola office sent paperwork to insurance

Sept 10 Called insurance and was told I was (for lack of a better term) denied

Sept 10 Called Yajaira (Dr. Ayoola’s Practice Manager/Insurance POC) informed her of the denial. She scheduled a peer-to-peer with BCBSIL Dr. Joseph for Sept 21)

Sept 17 Received denial letter

"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. (enlarged stoma- i don't know by how much)

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

Sept 20 I provided the following to give Dr. Ayoola so he can know more about me and my experiences when he has the peer to peer.

Dr. Ayoola
As you know, our request for my surgery was denied due to it is not medically necessary because my BMI is below 50 (my BMI is 46.8) and since I had a RNY gastric bypass in 2005, it presumes that I have not followed the prescribed nutritional program following the original (first) surgery. They also indicate that my EGD is shows a technical failure with my RNY.


Friday afternoon, you have a peer-to-peer discussion with my BCBS of IL insurance provider. I want to provide you with additional information that may assist you in fighting for my health.

History
- Roux en-Y in 2005
  • Successful in lost 115lbs.
  • My activity level drastically increased (nightly walks, long bike rides, hiking, swimming, canoeing, etc.).
  • I developed Hypoglycemia which I still struggle with today.
  • My sleep apnea severity was decrease, however, I still suffer from .
- A car accident In 2010 resulted in the following events.
- An undiagnosed broken foot for 2 months.
- A year after the surgery, I was still in constant pain which drastically limited my mobility.
- A different physician discovered I had loose bone fragments in my foot that resulted in another surgery.
- I have received many steroid shots over the years and wear a foot and ankle brace.
- The surgeries, steroid shots and brace help, but I’m still in constant pain.
- This year I went to an orthopedic surgeon:

  • Determined that the other 2 physicians missed that I had a bone fracture that has healed improperly.
  • The orthopedic surgeon informed me that I have severe arthritis that is greatly contributing to my pain.
  • I will be arranging another surgery to fix this so I can hopefully walk without pain.
- During the 8 years of pain and drastically reduced mobility, I slowly gained 65lbs. I suffer with:
- Constant pain in my foot and ankle.
- Regular lower back pain.
- Find it difficult to stand/walk/exercise.


Actions taken to improve my health.
- I was fitted for orthopedic inserts.
- I take medicine daily to help with inflammation.
- Started practicing yoga.
- Performed physical therapy.
- Received chiropractic treatments.
- Checked my metabolism.
- Multiple sessions with a nutritionist.


Motivation for Gastric Bypass Surgery
- My motivation for a gastric bypass surgery is to end this cycle of pain, discomfort and doctor visits due to my weight.
- It will give me the opportunity to lose a fair amount of my excess body fat which will reduce the pain in my foot and back.
- I will be able to be more active and enjoy my family, friends, volunteer organizations and in general participate more in life.
- I am hopeful that I will be cured of Hypoglycemia.
- I am hopeful that I will be cured of my sleep apnea.
- It will not only reduce my pain but also decrease doctor visits and end the need for taking some medication.


Likelihood of Post-Operative Compliance in All Respects, Including Dietary Restrictions and Behavioral Modification
- I successfully lost 115lbs after the RNY by following dietary restrictions and behavior modification.
- After my surgery in 2005, I continued a healthier lifestyle especially when I began gaining weight.
- I joined Weight Watchers, followed various diets and eating plans such as the Zone Diet, the Low Carb Diet, Adkins, etc.
- I tried various exercises with varying success- Farrell's 10-Week Fitness Challenge (included nutrition education), yoga, Couch to 5k, P90 program, walking around my neighborhood, biking, hiking, swimming, etc.
- Given I know what it is like to be lighter, I am yearning to be able to participate more in life.
- I have a strong likelihood of post-operative compliance in all respects.


Likelihood of Post-Operative Cooperation
- I am married and have a solid support system in place that will help me during the changes to my body and habits (eating and exercise).
- I regularly participate in one on one therapy that includes discussion of my progress and keep me strong through the challenges of the surgery.
- I have established support from online groups whose members are just like me.
- I will be joining a local group of folks that are working toward and maintaining weight loss.
- I use weight loss online websites and apps for food tracking.


Support Systems
- Celebrated my 10 year anniversary to my loving husband this year. He will help with my aftercare, changes in diet and exercise.
- My sister who has also struggled with her weight will be a great support.
- I participate in online support forums: ObesityHelp.com; Bariatric app; BariatricFacts.org, MyFitnessPal.com. The websites provide a wealth of information, encouragement, and support from others who have struggled with weight loss.


History of Addictive Behaviors, Including Alcohol and Drug Abuse, Anorexia and Bulimia
- I don't drink soda or eat at fast food restaurants
- I rarely consume alcohol and have never taken illegal substances
- I have never smoked
- I don't have anorexia
- I don't have bulimia


Sept 21 Peer to Peer: Dr. Ayoola met with the BCBS of IL Dr. Joseph. Yajaira (Dr. Ayoola’s Practice Manager/Insurance POC) informed me that I was denied for a technical failure with non-compliance. She said that they were proceeding with the appeal. Dr. Ayoola will be creating a narrative to provide to BCBSIL.

Note- If I understand their rules, I would be approved if my BMI is 50+


Not sure what to do now.

Thank you in advance for any help.
 
Last edited:
What is "technical failure?" Stretched stoma, asserted to be because of non-compliance? What EVIDENCE do they have of your non-compliance? Sounds to me like a failure of your surgery, not YOUR failure - because you were given the wrong surgery in the first place.
 
What is "technical failure?" Stretched stoma, asserted to be because of non-compliance? What EVIDENCE do they have of your non-compliance? Sounds to me like a failure of your surgery, not YOUR failure - because you were given the wrong surgery in the first place.

I have no idea what evidence they have other then me gaining weight.
I don't know how much my stoma was stretched.
 
Since BCBS IL is focused on the BMI and all my height measurements have been verbal, I had my height measured at my nutrition appointment today. My height is 5' 4.5" (I've shrunk!). My BMI is 48.57 with that correction. I sent the summary sheet with my height and weight to Dr. Ayoola's office and they will be updating my information in their system.

Question-
I was denied... "Deny 43659 (Lap Duodenal Switch) Medical Policy: Bariatric Surgery (SUR716.003) considers this service not medically necessary because your BMI is below 50.

If I were to have a BMI of 50, would I be approved?
 
Not necessarily. You need to read your EOC to see not just the bmi requirement, but also, and probably of more importance, their policy on revisions. Many policies have different, stricter criteria for revisions. Some don't cover them at all. It is much harder to get coverage for a revision than for a primary bariatric surgery, but you won't know what you are up against until you know the specifics of your policy regarding revision bariatric surgery.
 
I am
Not necessarily. You need to read your EOC to see not just the bmi requirement, but also, and probably of more importance, their policy on revisions. Many policies have different, stricter criteria for revisions. Some don't cover them at all. It is much harder to get coverage for a revision than for a primary bariatric surgery, but you won't know what you are up against until you know the specifics of your policy regarding revision bariatric surgery.

As Im not an expert in insurance....

BCBS of IL has a company (Accolade) that helps people understand their insurance policy. I specifically requested the EOC and they only found these 2 documents that had the following info:

1. PPO Plan Summary Plan Description
Blue Distinction Centers for Bariatric Surgery Charges incurred for bariatric surgery performed at a Blue Distinction Center for Bariatric Surgery will be considered Eligible Charges. Bariatric surgeries performed at any facility other than a BCBS Blue Distinction Center of Excellence for Bariatric Surgery will not be eligible for coverage. Dr. Ayoola and the location he performs surgeries are at a Blue Distinction Center for Bariatric Surgery

2. Medical Policies- Bariatric Surgery
For the Biliopancreatic bypass with duodenal switch may be considered medically necessary as a surgical treatment option for morbidly obese patience with a BMI of 50 kg/m² or greater who meet the other eligibility criteria for surgery.

The other eligibility criteria for surgery:
For a member to be considered eligible for benefit coverage of bariatric surgery to treat morbid obesity, the member must meet the following two criteria:
  1. Diagnosis of morbid obesity, defined as a: Body mass index (BMI) equal to or greater than 40 kg/meter²; I Meet This BMI = 48.57
  2. Documentation from the requesting surgical program that:
    • Growth is completed (generally, growth is considered completed by 18 years of age); I'm 47 AND
    • Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components: Spoke with Dr. Ayoola's Nutritionist on Aug 21
      • Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program; AND
      • Behavior modification or behavioral health interventions; AND
      • Counseling and instruction on exercise and increased physical activity; AND
      • Ongoing support for lifestyle changes to make and maintain appropriate choice that will reduce health risk factors and improve overall health; AND
    • Patient has completed an evaluation by a master’s level or higher behavioral healthcare provider acting within the scope of their licensure under applicable state law, within the 12 months preceding the request for surgery. This evaluation should document: Psych Eval completed and OKed July 5
      • The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations, AND
      • The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder, AND
      • The patient’s willingness to comply with preoperative and postoperative treatment plans.

Repeat/Revision of bariatric surgery: may be considered medically necessary only when specifically included as a benefit or covered service in the member’s benefit plan, summary plan description or contract AND when ALL of the following criteria are met:
  • For the original bariatric procedure, the patient met all the screening criteria including BMI requirements; I did AND
  • The patient has been compliant with a prescribed nutrition and exercise program following the original surgery; This is the reason they gave for denial AND
  • Technical surgical failure (e.g., dilatation of gastric pouch, gastrojejunal stoma (my stoma has increased), or gastrojejunostomy anastomosis; port leakage; or band slippage), has occurred that can only be addressed surgically; AND
  • The patient is requesting reinstitution of an acceptable bariatric surgical modality. I for darn sure have requested this!

I need help with this:
Dr. Ayoola is going to write up an appeal.... what can I do to help him write up this appeal since he really doesn't know me?
 
Yes. I did on Sept 17th. I copied it below which is directly quoted from the denial letter. There was no evidence provided.

Sept 17 Received denial letter

"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.(enlarged stoma- i don't know by how much)

Your physician may contact the Health Care Management Department to discuss this case with a physician adviser.
"
 
You need to ask what evidence they have that you were non-compliant. Is there something in your medical records? You need to know what they are claiming before you can rebut it.
 

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