Got my denial letter...unbelievable!!!

Got home from vacation yesterday...my denial letter from BCBS was waiting for me. Guess what it said...The request for a repeat bariatric procedure was not approved based on medical policy G-24 (which I will be requesting a copy of)...and then it says..."The patient has a rouy en Y bypass and lost weight successfully but has regained weight." WRONG!!!! I believe the definition of successful weight lose after WLS would be to have at least lost 55% of my excess weight. I have not been able to do so because of my dilated pouch and stoma...i.e. I need a revision. I have not regained weight. I have worked hard to maintain my weight for the past 2 years. All my doctors notes show my weight...last appt. in Ohio 335, May 2004...first appt. with surgeon here in Nov. 2004 337. I have some PCP notes in Ohio and here in between if I have to pull them out but come on like I lost down to goal and gained back up in 6 months. And by the way the 55% lost would still leave me at a BMI of over 45...so where 55% would technically be consider success...in order to be healthy and reduce my risks I need to lose more, and I know I could if I didn't have the problems I did. To me I should be able to call BCBS and tell them you didn't read file completely, I shouldn't have to appeal....you should have never made the decision you did!!!! I did that before when Cigna denied my garments, they said I could get them in network, I called them and said no I couldn't that I called the company they suggested and they could no supply me with what the doctor specified so they needed to overturn their original decision...and they did! Sarah Margaret

I'm sorry they are giving you this ridiculous run around. You have a good case - I hope you are going to keep fighting! Don't let them get you down. As we all know, they just want us to go away and give up - I truly hope you don't! I'll keep you in my prayers. Please keep us posted! Much love from Miami, Carol

Carol, I don't know how to give up!!! My policy states BCBS covers the treatment, including surgical, of morbid obesity...I'm MO...heck I'm still SMO...so they WILL cover my treatment!!! Sarah Margaret

That's what I wanted to hear!!! You go girl!!!!!

Fight it girl. You have good grounds to stand on. I hope you enjoyed your vacation.

Hang in there, girlfriend and give 'em h@!!. I think BCBS automatically denies most things the first time just to see if you'll keep fighting - so don't give up! Hugs! Vickie J.

I had medical policy G-24 faxed to me today, I actually spoke with the same lady who I was transfer to last week when I found out I was denied. It states...revision is medically neccessary when the patient has been unable to lose more than 50% of their excess weight. A revision is not medically neccessary if a patient has been substantially uncompliant. Since optimal weight lose can take up to 2 years to acheive a revision will not be covered within 2 years of the original surgery. O.K. so I have not lost 50% of my excess, my surgery was 3 years ago, my upper GI shows and enlarged pouch, endoscopy shows enlarged stoma, I have been following exercise and nutrition plans...documented since surgery....that how I have been able to maintain my weight and not regain and recently lose a little more...but still not enough. So...who's going to win their appeal...ME! BCBS doesn't know who they are dealing with!!! Sarah Margaret

Hang in there. I have faith that you will get it approved!