External Appeal upheld denial

Look above  for explanation...ty for responding

Don't get discouraged.

but while you wait to appeal again, you may need to keep a strict food diary & consult with a nutritionist to see if there is anything else you can do to increase your weight loss. This information can be used in your appeal to show you are serious. 

It is so important to stick to the rules that you were given post op. 

Good luck.

Hi Neongem,

i got a personal message requesting to see if i can help.  i haven't read all your post responses yet but u can pm me after i respond here if you would like..  Sheriberi asked me to follow up on your issue.  

yes i  was 3X  with the internal appeal(insurance co) the first one by material submitted to insurance co.  (they said i wasn't qualified because they didnt have enough information)  second was denied because after submitting all correct information they said my bmi was not high enough and third denial by them was by peer to peer (insurance and my doc over the phone) stating that is wasnt medically necessary

ARE YOU &%^& Serious i asked.. i was getting discouraged and was determined to have my revision from band to sleeve if it was the last thing i did on this earth so i reached out to MEXICO and thought i would deal with insurance when i get back..  after booking my flight and surgery in Mexico one week before my date of April 5 here at my doc's office i decided to do the NY STATE EXTERNAL APPEAL..  Go to www.NYSDFS (NYS department of Financial Services) and download the application.  i submitted it to my doctors office and he in turn sent (faxed)in 52 pages of supporting documents along with the application to NYSDFS.  Yes 52 pages of recorded visits of my lapband success lost 80 lbs until it failed me (thats recorded too in my medical chart) of band slippage numerous fills and unfills ,  Gerd  Acid reflux all medications that i was taking for the relief that never happened ect.. If your doctor could provide all of that there is no way you will not be approved.  The time frame from submission to NYSDFS to my tentative surgery date here in the US April 5 was about 3 days .. YES I Was APPROVED literally 24 hours before my April 5th surgery date.  i was able to cancel my trip to Mexico flight and all and Bill the coordinator in Mexico fully understood.  

Im not sure where you are being seen (i will go back and read thoroughly now as i wanted to get back to you asap)

A little history on me:    On January 26 2006 i had the lapband surgery at 5'9 and 250 lbs within 6 to 7 years i not only lost about 80 lbs more than my doctor expected but maintained it going from a size 20 to a size 10-12 (depending on the fit) the next 3 years i began having alot of gerd, unfills, fills,  unfills, fills,  complete unfill for 2 months fill again  slip xrays barium swallows (upper GI test) and gaining weight due to the unfills well in january of 2016 i decided thats it i cant take this anymore i called my docs office for my first revision consult and he completely agreed i was a great candidate for a revision and he had no doubt in his mind that i should NOT be approved.  he fought for me and i am greatly appreciative..

So with that said i wish you the best and please do not be afraid to call your insurance i called them every freakin day YES every day sometimes 2x.  Its your insurance know what your guidelines are your coverage ect..  

you can PM me if you would like.

I am going to go back and read some more of the replies posted.

Good Luck 

Your post is encouraging me as i had a similar experience except after 10 successful lap-band years, mine had to come off because of slippage. I'm exactly 3 years out and have gained back 50 lbs. I'm trying to get approved for the sleeve and it's not looking good. I especially can't understand the 6 mos of dietitian visits. That in itself is going to push me into next year and i've already met my out-of-pocket maximum for this year. Pretty discouraging...