>LONG< Secondary Ins.Revision Denial
Thank YOU for the encouraging words!!!!! This fight is NOT OVER!!!!!
I am SO GLAD to have this awsome board & the people on 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**
I don't kow how I missed this in my revision research, but I just recently found out that most insurance companies (including mine) classify revisions in one of two ways: 1) inadequate weight loss or 2) mechanical failure/complications. If you're submitting due to inadequate weight loss, then yes, the insurance company is going to require that you to meet the original patient criteria, whi*****ludes the supervised diet, weight history, etc.
Your letter of medical necessity mentions nothing about mechanical failure. I assume since you haven't had any GI tests, you don't know if mechanical failure is a possibility. Get your tests done and see if you can qualify citing mechanical failure/complications.
Anybody have any idea's???? BOTH of my insurance companies especially my primary WILL NOT cover ANYTHING. I have had to pay full price/cash-out of pocket for my monthly doctor visits & my phentermine prescription too.
This (the $$$$$$$) is the reason I have not had my PCP order any of the tests.... "fear" of getting stuck with expensive bills.
Primary Insurance exclusions wording:
WORD-FOR-WORD
PRIMARY INSURANCE (They are a "self-funded" insurance company.)
DEFINED TERMS:
Morbid Obesity is a serious disease associated with a high incidence of medical complications and a significantly shortened life span. The current clinical standard measure for Morbid Obesity is a BMI (Body Mass Index) of 40+. The BMI is a factor produced by dividing a person’s weight (in kilograms) by his/her height squared (in meters).
PLAN EXCLUSIONS
Obesity. Care and treatment of obesity, weight loss or dietary control whether or not it is, in any case, a part of the treatment plan for another Sickness. Medically Necessary non-surgical charges for Morbid Obesity will be covered.
Secondary Insurance exclusions wording:
WORD-FOR-WORD
SECONDARY INSURANCE
PLAN EXCLUSIONS AND LIMITATIONS
No medical benefits are payable for the following: Services which are primarily for weight-loss.
So, I feel "stuck between a rock & a hard place". But, I will keep fighting!!!! Thank YOU for all of the wisdom & words of encouragement!!!
-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 didn't read every word, but they've ruled out gastro-gastric fistula?
Michelle
RNY, distal, 10/5/94
P.S. My year + long absence has NOTHING to do with my WLS, or my type of WLS. See my profile.
According to my surgery report.... I have a common channel of 80.
We have never tested to see if I have a gastro-gastric fistula. I honestly do not even know what that is?
I always assumed that if it was something like that, I would have "some sort" of symptoms?I still need to have an EGD and/or an upper GI with contrast series done, according to the secondary insurance letter.
**I just have NO IDEA how to have either insurance company pay for my tests that they want?**
I'm thinking 'creative' billing? Sheesh, I dunno
-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**
A g-g fistula is a tiny bridge between your old stomach and pouch. In an xray, looks like a hair, but might be several. The net effect is that it acts like a staple line disruption. Allows acid to come UP, and food to trickle down into the old stomach, giving you "dual exhaust". So, your symptoms might include acid and/or ability to eat more. Some feel nothing but have regain they can't explain.
So, what are you looking to revise?
Michelle
RNY, distal, 10/5/94
P.S. My year + long absence has NOTHING to do with my WLS, or my type of WLS. See my profile.
THANK YOU for your wealth of knowledge and for sharing it with me!!!!
And a BIG Ahhhhh Haaaaaaaa.......
This might explain some things, with regain. I am looking into revising from my RNY to a DS. The stomach & intestine portion...... "The whole package"
Again, 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**
Michelle,
Thank YOU for the continued words of wisdom & ENCOURAGEMENT!!!!!!!!!
-Jamie
OK..... I have printed this entire thread out.
Tomorrow afternoon is my PCP appointment, and I am taking all of this valuable info with to my visit!!!!
I plan on walking out of that appointment with the upper GI/contrast scheduled!!!!! And, tentatively the EGD scheduled for a later date, like 2 weeks after the UGI.
Not sure on the EGD... since the insurance letter said EGD and/or UGI.
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**
