HELP!!! Appeal Hearing help

  I first want to preface this with the start of my revision journey. Back in January 2009, I went back to my PCP to “get back on track". Because I thought that gaining back 80 pounds, after my 18 month loosing window……. That WAS THE MAIN CAUSE FOR “MY FAILURE" at weight loss surgery. And, after researching, I found out that “I" was not the primary case for “MY" failure – but the actual surgical procedure had failed me  **This statement will become relevant later on in the post**

My Appeal Hearing is scheduled for November 16^th. It will be by teleconference and I do have permission to have Dr. Keshishian present in the teleconference as well.   I am looking for some pointers/rebuttals to help overturn my denied appeal for PRE-APPROVAL . According to the denial of the appeal, from the independent medical review:
1.        I am still a “success" with the RNY, because I have kept off 50% of my excess weight.

2.       The reviewer is a general surgeon in laparoscopic surgery. Not a background in bariatric surgery.

 3.       The review is also claiming my 5’ 4" then shrinkage to 5’ 3" to be a point as well. (a height discrepancy as they put it)I am over 250 as of right now, and I have a sway back, because of my excess weight, thus shrinkage. Not to mention we can tend to “shrink" as we get older, right?

4.       I had an EGD and a UGI done one in 2009 and then this spring with Dr. Keshishian who performed the EGD this spring. The review is calling into question the ‘conflicting results’ the 2009 UGI suggesting a very small pouch and a hiatal hernia and no ulcer, and the EGD performed by requesting provider suggesting a very large hiatal hernia, long pouch, and marginal ulcer.


Then the review goes on to state that I (the patient) has vitamin deficiencies, chronic diarrhea, chronic bloating at baseline all of which would likely worsen with a malabsorptive procedure. Given there is no overt anatomic complication of the primary RYGBP, the patient has maintained over an 87 pound weight loss and conflicting data on the patients height and diagnostic studies. Medical necessity of the requested procedure was not determined.  

a)      There is no overt anatomic complication of the primary RYGBP.

 b)      Per the UGI from 3/3/11, the patient has an intact RYGBP with a very small pouch.

 c)       No dilated outlet to explain abnormal dumping outside of dietary indiscretion and poor food choices

d)      Diarrhea and bloating will all worsen with fat malabsorbing diet. Evaluation of chronic IBS and why diarrhea is present (generally not a finding after RYGBP) should be determined.

e)      There are discrepancies in the medical record regarding height – not necessarily relevant for the patient whose BMI is till greater than 35 with sleep apnea, however, this is something to clarify

 f)       Medical notes from PAC reveal that the patient failed from poor habits – the patient admitted to falling off the wagon and given the patient has no obvious anatomic abnormality and was previously successful, going back to a true bariatric lifestyle diet should afford better weight loss or maintenance.  


Given that there is no overt anatomic complication, the patient is able to maintain her weight, and has symptoms that could easily worsen with a malabsorptive procedure. Medical necessity of a revision from RYGBP to DS is not determined at this time. Whereas the reversal of the RYGBP is rarely required, revision/reversal for a DS, although not common, occurs in greater than 4.7% of patients in one of the largest retrospective studies of revisions for DS, for such complications as protein malabsorption are most commonly and secondly, and secondly for diarrhea. Given that the patient reports chronic diarrhea of undetermined etiology, medical necessity of a conversion to DS was not determined.  


Julie Kim, MD
Board certified in: Surgery, fellowship trained in laparoscopic surgery



One thing that Sue said recently has stuck with me, regarding her researching a surgeon who turned down her daughters procedure & that doc was not even certified in that field!!!!!

oh Jamie,  this is tough....

a couple of things I noticed, your need to get a copy of you subscriber agreement and read and understand it very well.  you also need to know what he governing agencies for medical necessity (Dept of Health, Insurance commissioner, every state is different)  those last 2 are the most important for an appeal, without that information you are shooting in the dark. you would be amazed how they dont even know what is in their own contract, it is your right and responsibility to protect yourself and know it..   depending on many factors you appeal levels may require a surgeon who specializes in the same area as who order the surgery in other words for me a level 2 appeal would have to be denied by a surgeon who specialized in bariatrics, if hte insurance co doesn't have a dr, who specializes in that then they can't deny you (again that is specific to my dept of health for medical necessity cases) you should be able to get a copy of your entire record the insurance co has, what supporting documents they used to deny you, when they were reviewed etc.  sounds like they are looking for a "mechanical" failure of which they are saying you don't have, I mean your bmi is over 40 so you don't need co morbs.  depending on how the contract is written you may be able to get coverage without going in as a revision-again you would have to read the contract etc.   usually peer to peers don't go over very well, the ins. co knows they are coming, but Dr K is very knowledgeable, but I believe you will need more than "medical" help wth this.  I wish you all hte best, you have been fighting this mes for so long, hang in there, you never know what tomorrow will bring....keep fighting....

airbender,

You have very valid points!!!!  I have all of my prior denials.  I did get all of the documentation back from the insurance company.  I have a tough one here, in the case of the department of insurance, since I am in Alaska, and the insurance company is in Seattle, I did contact the State of Alaska division of insurance, and they have given me a few pointers and also a contact down in Washington, since that is where the insurance company is.  So I was glad that I took the initiative and contacted them to find out I need to deal with Washingon.

I have also read my rights to appeals and my right to this upcoming hearing from my insurance policy book.



Keep the good pointers coming!!!!!



THANK YOU!!!!!!
-Jamie 

i really have nothing to add but wishing you much good luck!  I do have a question though...above you reference Dr. Julie Kim in your post...I just wondered about this as I thought she was a bariatric surgeon in Boston, Massachusetts.  My surgeon is in Boston so I am familiar with most of the surgeons down there.

Valerie

Valerie,

This Dr. Julie Kim is on the WEST coast who the insurance company had do this last independent medical review.  And nowhere found on the medical review paperwork said anything about her background in bariatric surgery.  (See my original post - that had everything listed)

So, maybe there is more than one Dr. Julie Kim



-Jamie