RNY To DS - Waiting for appeal

Well, insurance authorization for my RNY to DS was denied and I have since submitted an appeal.  This time, I was sure to outline line- for-line how my case meets insurance's definition of medical necessity:

1. Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch (documented by upper gastrointestinal examination or endoscopy) - Both my radiologist and surgeon reviewed the UGI results.  My radiologist saying my pouch was mildly to moderately dilated. My surgeon referring to it as a large dilated pouch.
2. The initial procedure was successful in inducing weight loss prior to dilation - I lost down to a 22.8 BMI and kept my BMI under 25 for 3.5 years.  My BMI is currently 36.
3. Patient has been compliant with a prescribed nutrition and exercise program. - I submitted records of nutritionist appointments and weight loss program participation and well as health club memberships and purchase of a home treadmill.

So, those are the 3 requirement per my Member benefit handbook and I think I gave documentation of meeting all three.   I'm still so nervous that it will be denied a 2nd time.  I'm also concerned that I have other things that insurance isn't even looking for as problems.  In the last year, about 30 minutes after I eat, I have diarrhea (sorry, gross, I know) every time.  Could everything be passing through that quickly and that's why I seem to be hungry all the time?  It's troubling to think this could be another lifelong problem - or that the weight is going to get worse that it ever was before the first RNY.

I know I've seen a couple people referring to a law firm that helps represent clients against insurance denials.  Can anyone point me to their website or possibly give me more details on how that may work?

Thanks all!

Oh My Goodness!!!!!

So, I just got off the phone with my insurance trying to get the name of my grievance rep. and they said the denial has ALREADY been overturned.  YAY!!!  Now just to get a date!

WooHoo!!  Congratulations!

--gina

Way to fight for yourself!  Wow im glad it worked in your favor.  Have you picked a surgeon yet? 

It will be with Dr. K like you (I'm a lurker so I've seen many of your posts) :)

Are you doing better these days?

Yes everyday a little better. I guess I will be one that really needs 6 weeks. Probably because all my insides had to be cut apart.

Dear hansmom10,

It sounds like you have a physician picked out, care to share the name or any other helpful information. I have approval I just need a surgeon! Thanks, [email protected]