>LONG< Secondary Ins.Revision Denial
I already knew that my primary insurance was not going to approve. EBMS (Employee Benefit Management Service) They are 'self-funded'.
There is also more insurance information in my profile under April & May 2009
Here's the link to that post:
http://www.obesityhelp.com/forums/ds/4034048/Insurance-Updat e-x-post/#32711431
This is typed out word-for-word on the letter I received today, from the secondary insurance (Alaska United Food and Commercial Workers a.k.a = Safeway):
We forwarded you request to preauthorize revisional bariatric surgery for Jamie (Last Name) to the medical consultant for the Alaska United Food and Commercial Workers for an individual review.
After completing the review, the consultant has informed us that the submitted documentation does not support that revisional bariatric surgery is medically necessary for this patient at this time. The consultant indicated that "There needs to be a through dietary log to assess the possible role of poor food choices and dumping syndrome in this patient with weight gain. Additionally, this patient should be evaluated with upper endoscopy and/or contrast upper GI study to assess for a specific anatomic abnormality following a previous gastric bypass."
Since the proposed surgery was determined by the reviewer to not be medically necessary at this time, we will not be able to provide reimbursement toward the proposed surgery.
Please let me know if you have any questions, or if I can be of further assistance.
(Claims Operator Name)
OK........ So, I had my first appointment back in January of 2009. I weighed 235 pounds. My BMI was over 40 at that initial appointment. He put me on phentermine at that time, and I have been going into him monthly... every stinkn' month..... and we discuss the phentermine, exercise, diet... yada, yada, yada.
When I decided to look into having a revision, about March or April of this year (yes, initially, I thought I was the one who had failed my surgery).
If you have read this far.... THANK YOU!!!!
This following letter was signed by my PCP and given (one for primary & one for secondary) to the revision surgeon's office: (I assume it was given/submitted to the insurance companies with their paperwork packet)
Request for Pre-approval for Duodenal Switch surgery
To Whom It May Concern:
Mrs. (Last Name) has been under the care of ( PA-C's name here) for the past 9 plus years. She is 37 years of age, stands 5’3" tall and weighs 226 lbs. She has a history of childhood and adult obesity with a current BMI of 40.6.
Mrs. (Last Name)’s weight condition has caused her significant health problems, some of which appear to be getting progressively worse as time goes on. Some of this patient’s current health problems aregastro esophageal reflux disease (GERD), urinary stress incontinence, leg, ankle and hip pain, depression, and edema. Family medical history is positive for obesity, hypertension, diabetes, heart disease, and hypercholesterolemia.
Mrs. (Last Name) knows the health risk associated with morbid obesity and has done her best at attempts to control her weight. In an effort to resolve her weight problem, she has undergone numerous weight loss treatment plans such as:
| Diet | Date | Duration | Start Wt. | Loss | End Wt. |
| Phentermine | 1/09 | 7 months | 235 | 9 | 226 |
| Curves | 2/08 | 3 months | 233 | 15 | 218 |
| RNY | 2/02 | 7 years | 298 | 72 | 226 |
| Phen-Fen | 6/96 | 6 months | 278 | 59 | 219 |
| Atkins | 5/98 | 4 months | 280 | 5 | 275 |
| Low Calorie | 7/84 | 25 years off & on | 175 | +51 | 226 |
| TOPS | 7/84 | 5 years off & on | 175 | +85 | 260 |
Mrs. (Last Name) has been under the care of this office for the past nine plus years and within that time we have monitored her success/failure on weight loss programs. She is seeking rectification from her failed RNY. Unfortunately, it is causing her great pain and has had no long-term success. She is currently planning a revision to the Duodenal Switch.
Mrs. (Last Name) has been over 200 lbs for the past 22 years, with the exception of 2 years following her 2002 RNY, and up until a few years ago has been extremely lucky not to of have any major health concerns. Mrs. (Last Name)’s attempt at losing and re-gaining weight has only proven to cause her more health concerns. Mrs. (Last Name) is a very active female. She works as a clerk in the warehouse at the telephone company, which demands many hours standing and walking. Mrs. (Last Name) is experiencing severe pain in her knees and hips as well as ankle and calf swelling and unable to take anti-inflammatory (NSAIDS) due to her current RNY pouch. I believe weight loss would help to eliminate these symptoms. Mrs. (Last Name) also has a family history of diabetes. Her obesity places her at greater risk for adult-onset obesity; as nearly 80% of patients with this disease are obese. It is time for a permanent resolution to eliminate future health concerns related to morbid obesity.
I trust this information will aide you in understanding the true severity of Mrs. (Last Name)’s case and in facilitating the proper assessment. Please feel free to contact me if I can answer or clarify any questions you might have.
Sincerely, (PCP's signature)
OK, so, I understand needing the EGD & Upper GI.
Can anyone else help??!!?? Advice, insight?
PLEASE!!!!!!!!!!!!
It is difficult for me, since I live in Alaska, but I am willing to jump the hoops associated with that. Obviously... I will need more than one flight (I was planning one flight, to meet the DR a couple of days before my surgery... but after I had approval & a date) to California, where the revision DR is, to be able to have insurance pay for my revision.
-Jamie
*edited for grammar*
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
Thank YOU for the words of encouragement!!!!
And, you helped me (sometimes things appear to me "clear as mud") just by your statements!!!
I will start a food log & note when I feel ill or dump. Yes, the endoscopy & upper GI can be done up here in Alaska.
AND == words of wisdom from you give me HOPE!!!!
"but at least they did not exactly say no."
THANK YOU!!!!
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
I am so glad you responded, thank YOU!!!
**Unfortunately, I have no experience/expertise with appeals** (No clue) Any and ALL help/advice is MUCH appreciated by me.
PM me, if you would like, as well.
This, I DO know about my primary insurance..... 2 other ladies, in the last 2 1/2-3 years have had WLS, and self-paid.
The first lady said since our company is 'self-funded' the appeal process/decision is up to the company CEO & he denied her. She found out about the first denial, and self-paid anyways. And, then, tried to get re-imbursed, and it was the CEO's decision (he works in the same building that we do) and she was never given any money for it.
My thought are that she should have waited it out, and not had surgery... but, this is what her story was. (she and the other co-worker did not have the DS, but did have WLS).
I will do a little more investigating about the other co-worker who had her WLS 8 months ago, and see if she even tried to get our company insurance to pay, or if she avoided that all together, and just paid cash to be done with it.
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
Larra and I have some very recent appeal letters for revisions that we might be able to share with you (I'm not sure whether we have a redacted version yet -- that might take some work to fix up). Send me a PM with your email address -- it isn't possible to send attachments through OH.
And, again THANK YOU for always Paying It Foward!!!
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
Then do what they say they need. You've got the monthly meetings with your doc. Sounds like he/she is a good writer, so you can be fairly sure that the notes/report that the doc sends to the insurance co will have the details that they need. My insurance co needed to have the vital signs as well as weight and BMI for all those visits. They also wanted visit notes to state that we discussed diet, weight loss, my comp[iance, and results. "Pt is compliant with stated plan" is a very good phrase to have in the reports. Make sure it's in a form that makes it obvious to the dumbest person in the world that you are fulfilling every one of their requirements.
I ended up having to have a lawyer write the second appeal letter, and was approved righ afterwards. I had done all the footwork, and the appeal was put together, and he "just" added the legalese and bashed them over the heads with it. I say "just" in quotes, because that letter was a thing of BEAUTY.
Good luck. You can do this. The insurance rigamarole is pretty much the hardest part of the whole process, imho.
Dennie
"It's so beautifully arranged on the plate - you know someone's fingers have been all over it. ~Julia Child"
Thanks for the positivity of your thoughts & words!!!!
I appreciate it!!! Good tip, on the keeping track of names & what is discussed.
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
KAREN W.
I LOVE MY DS!!!!!
STRIVE TO BE THE BEST YOU CAN BE AND DO THE BEST THAT YOU CAN.
Check out www.dsfacts.com and www.duodenalswitch.com for all the accurate information on the great DS, and find surgeons in your area or around the country or out of the country.
I couldn't have done without all the great peeps on this board. 
SW: 234.5 CW: 157 GW: 140 - ish
