External Appeal upheld denial

Hi all, been a long time....will be 9 yrs out and I've gained about half my weight back....so was going to have revision, jumped thru all the hoops, did all the testing and weigh ins etc. Was denied twice and just got the external appeal decision that they are upholding my insurance carrier's decision. Denied. So my question is.....how long do I have to wait to try this whole thing again? Or am I denied for life? Trying not to be completely devastated by this.

Don't give up yet... A friend of mine on here had the same thing happen , external review was upheld and she had booked a flight and gotten a surgery date in Mexico when someone gave her some legal advise and she took one more step and was approved . I will try to reach her and see if she can reach out to you and let you know what she did . Also, you need to contact lindstrom obesity advocates and speak to Kelly .... Tell her what's going on and she will tell you honestly if she can help you or not .... Hang in there and don't give up yet! 

Thanks for responding.....honestly, I'm not gonna she'll out money to an attorney, money I don't have. Sigh

It's a flat fee and very reasonable considering the cost of surgery, I believe it was $500. 

Was wondering ... Did they find anything wrong that they believe is causing the tool not to work properly anymore ? 

What was the reason for denial? 

Unfortunately - if the tool works - and the is no medical reason for weight gain or complication from the original surgery - just the weight gain may not be a good reason for insurance to approve a revision. 

Is your tool still working? 

At one time I regained app 35 lbs from my lowest. It was my eating and...some social alcohol drinking that contributed to the regain. Eating the wrong things, lack of movement (i never exercised much) and just overall eating too much and too often - grazing. 

Once I decided "enough" ...and I put myself on the RNY "diet" I lost my regain. It was not easy or fast - but my tool is still working and as long as I use it, and the food scale, MFP for food journaling, fitbit to track how much I move, etc...the extra weight came off... 

I know it is very hard...but can you try to get back to basics? Proteins + non starchy veggies, healthy fat ...

It can be done...

My motto is "one meal at a time, one day at a time" ...if you "slip up" start all over at the next meal... 

Well the first denial and two appeals were because it wasn't a medical necessity. External appeal denied because they didn't do an endoscopy with contrast to find out if it's a mechanical problem with pouch and connection.

Unfortunately your docs could not show medical reason for the first WLS failure.  And just gaining weight is not medical necessity for most insurances.

How do you think new surgery will help you lose the regain?  Why, since you are denied - not start the real RNY diet and lose it?  What you were hoping to revise to?  

No WLS will work of the patient does not follow the strict rules.  

Most people with revision lose slower and takes longer to lose, and regains also happen, even with revision.

The only good revision from RNY to help with a weight loss is really DS.. But there are a very few docs in the whole world who can do that properly. 

And the complications due to revisions are way too many...and that surgery is very very risky. 

Beside DS any other revision of RNY show a very small weight loss. And a short term only...

Some docs revise from proximal RNY to distal...but that can have so many negative side effects that not many docs are willing to do those. 

Changing what you eat and how much can help you lose the regain. I know...I've done it. And it was not easy...

Good luck. 

If you've been denied three times by the same insurance, it's unlikely they'd approve unless there's a drastic change to your health situation.

You might have better luck with a different insurance plan, depending on why you were denied.

What is the reason for denial?   Does not meet medical necessity, etc?

I have worked in the insurance industry for over 25 years and in both hospitals and physician's offices.  If I you can give me the denial reason, I might be able to assist.  

You can PM me if you prefer not to post publicly.   

~Nik