x-post: *******s denied me!
Ok OH family, I need your assistance. My insurance company has denied my request for revision: this is what was said in my letter:
"after consideration of all available information, our medical director has determined that the requested procedure will not be covered for the following reason(s): based on your health plan criteria this request for weigh reduction surgery cannot be approved at this time. Your bmi of 38.2, there is no history of Type 2 Diabetes Mellitus or heart disease. No high blood pressure, no cardiopulmonary problems. Medical criteria not met".
So i went back and read my policy for bariatric surgery, so I guess I should eat myself to a bmi of 40 in order to get approved. This is some BS! SMDH! I gotta figure out what to do next.
Frankie
"after consideration of all available information, our medical director has determined that the requested procedure will not be covered for the following reason(s): based on your health plan criteria this request for weigh reduction surgery cannot be approved at this time. Your bmi of 38.2, there is no history of Type 2 Diabetes Mellitus or heart disease. No high blood pressure, no cardiopulmonary problems. Medical criteria not met".
So i went back and read my policy for bariatric surgery, so I guess I should eat myself to a bmi of 40 in order to get approved. This is some BS! SMDH! I gotta figure out what to do next.
Frankie
Do you by any chance have sleep apnea? Significant osteoarthritis in weight bearing joints? These might help you to meet standard medical criteria for wls.
I'm hoping Dr. Roslin can help you. He has a reputation as someone *****ally fights to get approval for his patients. It sounds, from some of your prior posts, like your stoma may be stretched out, which would mean that whatever you eat just falls right out of your pouch and into the small intestine, leading to frequent hunger and weight gain (and also reactive hypogoycemia). This might constitute a mechanical failure of your prior RNY and grounds for revision.
Bottom line, let Dr. R. know and I hope he can help you.
Larra
I'm hoping Dr. Roslin can help you. He has a reputation as someone *****ally fights to get approval for his patients. It sounds, from some of your prior posts, like your stoma may be stretched out, which would mean that whatever you eat just falls right out of your pouch and into the small intestine, leading to frequent hunger and weight gain (and also reactive hypogoycemia). This might constitute a mechanical failure of your prior RNY and grounds for revision.
Bottom line, let Dr. R. know and I hope he can help you.
Larra
My BMI is 38 and I was just approved. I didn't have high blood pressure, heart problems, heart disease or diabetes either! Because of this I gathered as much as I could to prove I needed this surgery!I found what comorbidities I DO have that could help.
I have a migraine disorder so I asked my neurologist for a letter of recommendation. I also asked my OB and my PC for one! So I had three. Do you ever see another DR for health issues besides your PC that you could plead your case to for another letter?
Also, do you have GERD? Depression? Diverticulitis??Research what comorbidites you DO have. My insurance said I had to have at least two. read and Find out how many yours has
Get as much ammo as you can and then appeal!
Best of luck and!!
I have a migraine disorder so I asked my neurologist for a letter of recommendation. I also asked my OB and my PC for one! So I had three. Do you ever see another DR for health issues besides your PC that you could plead your case to for another letter?
Also, do you have GERD? Depression? Diverticulitis??Research what comorbidites you DO have. My insurance said I had to have at least two. read and Find out how many yours has
Get as much ammo as you can and then appeal!
Best of luck and!!
At the risk of being the unpopular post, please take this the way it was intended, not to be a dig or anything.
From the information in your post, there really is no grounds for appeal at this time.... I mean, yes, under the law you have the RIGHT to an appeal process... but apealing won't raise your BMI to 40+, nor will it give you a QUALIFYING co-morbidity.
Yes, some of the other suggestions like GERD, arthritis, sleep apnea (by itself without other pulmonary issues), depression, etc ARE co-morbidities, but they typically are not QUALIFYING co-morbidities under accepted medical standards (no matter how many of them you may have). There are really very few qualifying co-morbs such as diabetes-II, and cardio-pulmonary issues.
At 38.2, you're not really THAT far away... wouldn't be much of a stretch to gain a few lbs to bring your BMI up to 40
as nit-picky as it sounds, they have to draw the line SOMEWHERE, and unfortunately for your desires you're not quite over the line.
You would have been better off with an e/i denial (Experimental/investigational) rather than a criteria denial... at least with the e/i, there is plenty enough literature to fight the e/i claim. no amount of literature will raise your BMI or give you a qualifying co-morb
I've been on both ends of it... I fought and won my e/i denial close to 5 years ago... and now for a while have been working for a major health ins. company and have learned many of the ins and outs of the review process.
In any event, I wish you the best of luck.
Out of curiosity (and if you're comfortable telling), what's your insurance co?
From the information in your post, there really is no grounds for appeal at this time.... I mean, yes, under the law you have the RIGHT to an appeal process... but apealing won't raise your BMI to 40+, nor will it give you a QUALIFYING co-morbidity.
Yes, some of the other suggestions like GERD, arthritis, sleep apnea (by itself without other pulmonary issues), depression, etc ARE co-morbidities, but they typically are not QUALIFYING co-morbidities under accepted medical standards (no matter how many of them you may have). There are really very few qualifying co-morbs such as diabetes-II, and cardio-pulmonary issues.
At 38.2, you're not really THAT far away... wouldn't be much of a stretch to gain a few lbs to bring your BMI up to 40
as nit-picky as it sounds, they have to draw the line SOMEWHERE, and unfortunately for your desires you're not quite over the line.
You would have been better off with an e/i denial (Experimental/investigational) rather than a criteria denial... at least with the e/i, there is plenty enough literature to fight the e/i claim. no amount of literature will raise your BMI or give you a qualifying co-morb
I've been on both ends of it... I fought and won my e/i denial close to 5 years ago... and now for a while have been working for a major health ins. company and have learned many of the ins and outs of the review process.
In any event, I wish you the best of luck.
Out of curiosity (and if you're comfortable telling), what's your insurance co?
Pre: 324 
Now: 185-190 
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