@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
- 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:
- 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.
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 .
- 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.
- 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.
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