Was recommended to come here for help and support

[Yvonne]

I sure hope you'll all bear with me. You need to hear the story in order to maybe/hopefully?? have some advice. I was invited by Lara to come over here from OH. She suggested that DianaCox would be able to help me or at least offer advice. So here's my story:


I started this in November of last year. I have PCOS and have tried about every diet known to man and really don’t lose well on anything. My insulin runs high all the time (around 19 – top of normal although my Endo told me she’d like to see it at 4). I had a lap band placed in July 2015 against my Endos’ advice. He (this was a different doctor a long time ago) said “I’ve seen you eat 800 calories a day and you didn’t lose weight. Until we can get your insulin down it won’t work”. I lost about 70lbs (I’m obsessively compliant – great for the DS), then I just stopped. My weight crept back up at 25lbs and then I just sat there for years.

Well, I’ve gotten older and the weight, plus the PCOS has just reared its ugly head and I started having trouble with my blood pressure. In January of 2013 I started going to a weight loss doctor (not surgeon) that worked with hormones. He was sure he could help with the insulin. Nope. After going to him until April 2015, I found a new GP and we started on new meds for blood pressure. One she put me on (which we didn’t know) shot my insulin through the roof. I was at 38 from April – November. I gained 5-7lbs a month every month with no change in diet. Then “I” figured it out by research and I went off of it (I discussed it with her of course). I stopped gaining but never lost any of that. I was devastated – 80 POUNDS heavier. I have Fibromyalgia and honestly, I function pretty well, until all the weight gain. I am in college at 49 years old and now I’m falling down because my leg goes numb from the extra weight and all these parts of my body that never hurt are hurting. I walk like an old woman and need help down stairs and forget walking upstairs. If there is no elevator I wait at the bottom. We tried everything (I’m on 3 pills and it’s only OK right now), but my blood pressure is still not normal.

That’s when we decided to do something more. I went to a new Endo (as mentioned above and she suggested a RNY). I didn’t’ really want that but I didn’t know of anything else. So that’s when I went to the bariatric doctor that she suggested here in town. He thought the RNY would not allow enough weight loss (I have a BMI of 56.9 and need to lose about 200lbs). He suggested the SADI. He also said that if he can’t get the Lapland out in enough time I’ll wake up with a SLEEVE. Which makes me about as excited as I am now about my Lapland. Now of course, I still had never heard about the DS, so I figured that would be great, after all it’s “just like the DS only improved”. I should have just gone to Dr. Inman at this point, but I was so excited to have a doctor so close so I could go to support meetings, etc. Well, he submitted it as band removal (no mention of me going to that weight loss doctor for 16 months straight – CASH $100-$200 an appointment), not much mention of problems with my band, other than a “little reflux” and then the SADII was coded as sleeve and also Misc. gastric procedure. Yeah, I know I know. I meanwhile started studying up and realized, maybe I should be going with the DS. But I pushed on. My insurance denied my band removal saying that even though I can't tolerate it, it is functionally fine. They see no reason for additional bariatric procedures for my obesity. He immediately did a peer to peer and THAT was denied. It was done by a Gastro doctor at the insurance company that said “I’m not sure why they’re having me do this, it’s not my field. But I’ll pass it on to appeals”. THAT was denied. I have NO fluid in my band and I choke on food daily, have severe reflux that IS controlled by Prilosec, but the 10 years of Prilosec, has caused my stomach to be full of polyps. But because it's not "broken" they won't pay for its removal. Even though my BMI is 56.9, they said there is no need for Bariatric surgery.

I picked up the phone and called Lindstrom and have paid them the $800 of the $900 (I have one more installment payment). I started with them at the end of June and I have yet to have an appeal sent in. It’s is not entirely their fault (not that I’m blaming them), but it took my SURGEON’S office 3+ weeks to send my files to them. Now we can only do a “telephone testimonial”, which is finally scheduled for September 8th.

I have literally been jerked around for MONTHS (from everyone). I jumped through everyone's hoops (all my psych stuff and dietetics are done) and whatever else they asked for. I started this process in November 2014 and was hoping for surgery in May or at least early summer as I'm a full-time student. So here it is, school just started this week, and no surgery. I also have an $8000 deductible that I have all but met due to all the preliminary stuff. In fact I'm almost to my stop-loss and at least part if not most of my surgery will be covered at 100%. That gives you an idea of how much I've spent trying to have this surgery. Now I find out my surgeon hurt his wrist on vacation last week and will need surgery to fix it. They not only don't know/or won't tell anyone WHEN he's having it, but can't give us an idea of when he'll be back to surgery. I can NOT have this go into next year. It will bankrupt us (new $8000 deductible starts again

I had my lap band at this hospital where Dr. Inman is at and LOVED it there (the one that is so far away). I have a whole lot of friends that are happy to drive to appointments with me (my husband was having to take off all kinds of work to go with me - he would still go to important ones, just not every single one).

OK, so if you made it to the end, boy do I appreciate your continued interest. Here are the questions. I know some of you have used attorneys and I believe someone told me that they used Lindstrom before. Did it take as long as this to get things going? What do you suggest I do about the attorney/new surgery submission? The new surgery will be coded completely different. Should I have the new surgeon submit a new surgery precertification request and I tell the attorney to sit on hold in case I need them (I am happy to finish paying them as that is what I promised to do. OK, not happy, but understand my responsibility). Do you think they’ll say “too bad so sad, new surgery, new $900”? Keeping in mind they have not submitted anything for me yet. As far as I know the appeal hasn’t even been finished as I’m supposed to get a copy of it when he’s done with it before the phone testimonial. I have my consultation appointment with Dr. Inman on September 17th. Should I call the attorney now and tell them what’s going on? Any suggestions? Honestly, I can’t wait around for the other surgeon to ‘get better’ especially having NO idea how long that will even be, oh and every person approved before me goes on a list before me, oh and I DON’T want the SADI now. One quick note. I had a regular doctor’s appointment yesterday and she said “Perhaps the whole reason this has taken so long and nothing has gone through is because you aren’t supposed to have it locally and should be having it with this other surgeon 2 hrs away.” Help?

 

[Charris]

Wow. I have no clue to most of your questions but I do know that @Larra and @DianaCox know their stuff. Personally I'd be inclined to go to one of the super power DS doctors if anyway possible they know exactly what to say to make it happen. Honestly I've never heard anyone denied to have surgery with them. DOESN'T mean it hasn't happened but I'm sure the denial rate is much lower.

 

[Yvonne]

Wow. I have no clue to most of your questions but I do know that @Larra and @DianaCox know their stuff. Personally I'd be inclined to go to one of the super power DS doctors if anyway possible they know exactly what to say to make it happen. Honestly I've never heard anyone denied to have surgery with them. DOESN'T mean it hasn't happened but I'm sure the denial rate is much lower.

Thank you for tagging them. I wasn't sure how to do that.

 

[newanatomy]

Wow, you have had a rough time! I hope Diana can help you! Welcome to the forum.

 

[DianaCox]

I'd be willing to bet 10 lbs of bacon that Walter hasn't done a stitch of work on your case yet. He uses a template and plugs your info in it (or at least that's what I figured out the one time I reviewed one of his letters and all the pronouns were "she" and the patient was obviously a man's name - it might have even mentioned menstrual problems). Tell him not to start on the letter yet (and just treat it like you assume he hasn't) until you get the surgeon situation straightened out. And tell him when you do finalize the details, you don't want him to send it out before you review it.

In the meantime, I'd like to see the previous submissions to the insurance company, the denial letters and your evidence of coverage document - the FULL contract.

 

[Yvonne]

What about the phone testimonial that is scheduled on September 8th with Walter, the Gastro doc that denied me and I? My appointment with Dr Inman isn't until September 17th. Also, I have copies of the denials but as for original submission, would I get those from the original doctor? Do I tell the original surgeon that I'm going somewhere else? Our insurance has been very hard to get paper copies of anything. One time the nurse at the original surgeon's office had a copy. It's about 9 pages long. She showed it to me. Can I call the insurance company and request a copy of it? Thank you SO much for your help. I should have listened to you in the 1st place. I'm sorry.

Yvonne

 

[southernlady]

Welcome @Yvonne
Sorry you are going thru all this but you have both @Larra and @DianaCox in your corner.

Thank you for tagging them. I wasn't sure how to do that.

How to tag: Type the at symbol @ and then start typing their name...NO spaces between the @ and their name or it won't work. When it sees enough letters, options pop up and you can click on the correct one.

 

[Larra]

Hi Yvonne!

As @DianaCox said we need to see the EOC (evidence of coverage, a long document, not the summary) and all the other stuff she mentioned. You should be able to get the records of all the tests and evals you have already had from the prior surgeon to give to Dr. Inman. It's probably just as well that you don't want the SADI because it isn't a standard of care operation and there is no insurance code for it, so some surgeons are using the DS code (and it isn't really the DS) and others sand cobbling existing codes together rather creatively, which may come back to bite them and the patient in the butt at a future date.

Is there any way to get the phone testimonial postponed til after your appointment with Dr. Inman, and get her involved in it? She is a genuine and experienced DS surgeon and I would bet she's seen other patients with lap band problems and would be much better able to make a strong case for you.

Regarding only getting a sleeve, of course I can't speak for Dr. Inman, but I would bet that would only happen if your lap band has created extremely bad scar tissue that takes a very long time to deal with. That does happen sometimes, but most of the time the band can be removed and the full DS done at the same time. If you did get only the sleeve, you would still be much better off than you are now, and she could do the rest of the DS at a later date. Not ideal, but better than living as you are now for sure.

 

[DianaCox]

You get the EoC from your employer, not the onsurance company (unless it is an individual plan, of course).

I can't answer your question about the denial of the peer to peer until I know why it was denied. If it was denied because they are claiming that your surgery is not a covered benefit, you have to do an administrative appeal rather than medical - it's a different process.

 

[Yvonne]

The nurse at the original surgeon's office told me that she got the EOC from the insurance company. I call my husband's company and they have no idea about anything = no help. I remember the day they used to send you one. I understand about paper waste etc., but in these times... The "waking up with only a sleeve" was the original surgeon, not Dr. Inman. I'm guessing Dr. Inman might do further tests to see all about my band. The Endoscope can only show so much, maybe a Barium Swallow? Who knows. I will scan the two denials now and send them to the board on a another post and work on Monday getting the other information.

Looks like I'm going to have to bite the bullet and tell my original surgeon I'm not using them. Agg. I hate that type of confrontation. But it won't stop me from doing it.

@Larra The phone testimonial is for the original surgeon and and the SADI and the band removal. I don't want that surgery, so shouldn't we just cancel it all together? I'm assuming, I should talk to the attorney as soon as I can and tell them what I am doing. They are the ones who set up the phone testimonial. Yes, it seems they were cobbling it together. I specifically asked my insurance which codes they had submitted, they gave me the codes and a link to where I could see what it was describing. It was 3 codes. To remove the band, to do a sleeve and the "miscellaneous gastric procedure".

@DianaCox - the original appeal said basically the band was not unfunctional, therefore they won't pay to have it out. The other procedure was because I hadn't "dieted" enough. Going to that one bariatric doctor (not surgeon) from January 2013 to April 2014 isn't enough? Plus I did the whole dietetics thing. My plan is very UNSPECIFIC. Even the long version. Just says something like a reasonable attempt to lose weight. The peer to peer was basically the same. My band was functional even though I can't tolerate it (their words) and then they said I didn't have a recent psych eval, which I just had one done and it went in with the original submission (March 2015) and that they didn't see any need for a bariatric procedure for my obesity. But again, this was a gastro doc making this decision, not even a Bariatric surgeon reviewing it. But I will find that stuff and get it to you guys.

Oh and my attorney has that information. I could ask her to send it to me as attachments. I know she's sent other things to me that way. It's all scanned it already. All she'd have to do is just attach them to an email and send them. Looks like I need to call the attorney on Monday morning.

Thanks again!

Yvonne

 

[Larra]

You are entitled to a copy of your EOC, either on paper or on line. Keep going up the food chain until you get someone helpful. Be polite but be persistent. Document every phone contact with name, job title, date, time, phone number, and brief summary of conversation. Get stuff documented in emails if possible, even if you have to start the email chain. You never know what you will need down the line.

Re: the phone testimonial, given that it was original surgeon and SADI, I agree that cancelling altogether is a good idea. With most insurance policies you have only so many appeals chances. If you waste one, it's gone forever. So cancel.

I'm getting the feeling (would value @DianaCox opinion) that we are going to need to prepare a formal letter of appeal documenting your problems with the band, your dieting efforts, your medical necessity for bariatric surgery and the DS in particular, etc. However, before we can do this, we all need your EOC and the previous denials and anything else you have. then we can supply you with an outline to get you started, and review and edit your letter to make sure it's as strong as possible and that there is nothing in it that would hurt your appeal.

I'm going to let Diana comment on what, if anything, you are doing with your attorney, because she's an attorney and I'm not. However, I will say that most attorneys have no idea how to go about this, and what the issues are, and what the reviewer is looking for to justify forcing your insurer to spend a whole bunch of money on another operation.

 

[Yvonne]

Ok, great. I will get a copy of my EOC. Come hell or high water. I'm pretty persistent. I'm in school to be a Social Worker to work with teens and I plan to go before Congress if I have to in order to protect them and their rights when it comes to anti-bullying laws etc. I had it out the other night with one of our state Representatives. In the nicest and firmest way. I'm pretty tenacious when something is important. I told my husband, I really believe if I don't have this surgery I will die young and I have far too much to do and way to many kids to help before I'm gone. I do have a way of charming people to do what I want, so I'm sure I'll have a copy soon enough. I'd really rather not have any contact with the other surgeon if I can avoid it. I live in a pretty small town and it's possible I'll work at that hospital at some time. I'm almost positive that the attorney has a copy of the EOC and I'd bet she'd be happy to send me a copy via email. I just remember it's really long.

I'm wondering if this is even something that should be said about my band. My MAIN problem is insulin. I'm a awesome dieter (as most obese folks are), and not much helps to lose. In fact I was eating 800 calories a day before my band. My Endo said until I get my high insulin lowered not much will help. Since the band is about caloric restriction, and the malabsorptive surgeries work wonders for diabetes/insulin problems that is the key for me to get things moving. I'm not sure how much a non-bariatric doctor is going to understand that. But it's what I'm banking on. I am also so sick now from the obesity related stuff that would be resolved with quick weight loss, that I can't understand why this is so difficult. Even the non-responsive high blood pressure is one example. So yes, we may have to prove it.

You are being so generous with your time and help.Thank you.

Yvonne

 

[hilary1617]

Just wanted to say welcome and that I wish you a positive outcome!

 

[brooklyngirl]

I have nothing helpful to add, so I'll just second what Hilary said and give you a welcome and a virtual {{{hug}}}!

 

[Yvonne]

Just wanted to say welcome and that I wish you a positive outcome!

Thank you. You look like you've been through quite a lot yourself. I appreciate the support.

Yvonne