New to Group

[Jillian Heinrich]

Hi!! I’m Jill! I’m new to the group. I’m looking at have a revision surgery from RNY to DS with Dr. Keshishian in Pasadena, CA. Sadly, I’m running into insurance denial problems stating my overall BMI isn’t high enough, despite the insurance policy being vague in citing your “original BMI” needs to be a qualifying number of 50 or greater. To my interpretation, “original BMI” would be pre-surgery of any kind, which in that case, my BMI was a qualifying number. If anyone has any incite or advice as how to appeal BCBS-ILLINOIS PPO, I would be greatly appreciative.

Thank You-

Jill

 

[southernlady]

Welcome Jillian Heinrich

 

[DianaCox]

1) You can - and should - make that argument regarding your "original" weight.
2) It will be another arrow in your quiver - the REAL arguments are (a) there is no scientific justification for limiting access to the DS, which is a standard-of-care procedure, to SMO people, either before their original surgery or after their original surgery failed; (b) in fact, SMO people who receive a lesser surgery as their original surgery are statistically highly likely to fail, and after a failed surgery, it's even harder to lose weight after a revision, which should mandate the DS as a revision surgery; and (c) the ASMBS supports the use of the DS as a revisional procedure after failure of the original procedure: https://asmbs.org/resources/systematic-review-on-reoperative

You need to get a copy of your Explanation of Benefits (EOB), which is your FULL insurance plan document (at least 80 pages, not a summary of benefits), and a copy of the bariatric policy that applies to YOUR plan (BCBS-IL has lots of plans). You probably need to get your EOB from your HR department. Have you received a denial yet? Also, ask your HR person whether your insurance is fully funded or self funded.

No promises, but Larra and I work together as a team to help people with insurance issues for the DS, and we win the vast majority of the time. (Patting myself on the back is the most exercise I'm gonna get today, since it's 7:30 PM and I'm still in my jammies, but I got work done today.)

 

[JackieOnLine]

Hi Jill and welcome. you are in the right place!

 

[hilary1617]

Hi and welcome Jillian Heinrich! You will be in great hands with Dr. K!

 

[Munchkin]

Welcome Jillian!

 

[ElizaStone]

Hey there!

 

[Spiky Bugger]

I may come visit you...I was born at that hospital!

Sue