So frustrated at everything right now.
on 12/1/12 11:00 am - Mesquite, TX
Tired of my RNY surgery issues... tired of pain... tired of all my health issues. Just feel like a pity party. Wish my mom was alive so I could go cry on her shoulder. lol
I just feel like such a failure with my weightloss. I am in pain and do not want exploratory surgery to figure out what is up... and then another surgery for revision. I am dealing with this daily pain and praying to get my revision surgery and to find out the cause of this horrible pain soon!! Ugh I hate insurance and doctors offices.
It is also so frustrating... then to have medical staff tell you to just gain a little weight. I am gaining like crazy and don't know why! 
My BMI is not high enough and the insurance seems to only be looking at it.. not all the other issues and problems I am having. GRRRR
I just don't know what to do. I hate calling and bothering the staff... I feel like such a bother when I do. It doesn't really help me either, they just tell me to gain weight and then insurance will approve. At the rate I am gaining, I should get approved before long. CALGON TAKE ME AWAY!
I am sorry you are going through this. I am a precert nurse at an ins company which I just passed my 90 day anniversary and WLS are part of my job. Thankfully this portion of my job is limited as it kind of boring. As a nurse I am unable to deny as any denial must go back to the medical director. I work for the federal side of the ins company so I know the requirements for that but I also sit with the commercial precert nurses and have heard some of their basic requirements. Thankfully I currently work for an ins company who is for the mbr as the prior ins company I worked for was not and bypass was like a dirty word. The moment they heard it they would look for reason to deny if someone had complications. Any way point is there is certain criteria we must go through in order to get a mbr to meet. If we approve the mbr all criteria has been met however if for some reason a mbr did not meet a certain criteria I have learned from other nurses training me there are ways to write up a request which will more likely be approved by the medical director. For example there are 2 very common criteria used out there by insurance companies one is Milliman and the other is IQ the guide lines are black and white if we are looking to approve a CABG, total hip or a Gastric Bypass. The nurses have learned over time if they word things like Mbr almost meets it more apt to be approved then if they were to write mbr does not meet criteria. I personally have witnessed at least one side of a conversation in which a mbr called in and spoke to a commercial precert nurse and after the call the nurse was more invested and wanted to help the person. In this particular situation the gal/mbr was in tears & I heard the nurse consoling the mbr which got my attention, I assume the mbr must have been very frustrated to get to the point of tears and I can remember feeling that way. What I take away from this situation is the squeaky wheel always gets the attention so please do not feel it is a waste of time do call. If you are not getting the answers you want find out exactly what is preventing you from meeting the criteria for a revision and ask for it in writing and then meet those guide lines. I hope this helps as I know how frustrating it is. I am or rather was a so called light lite not sure which is the correct spelling any way I had a failed lap band. I paid for the procedure myself and I only lost 16 pounds and was miserable. At my top wt of 207 I committed to the DS and again I had to personally pay. Take the time if you got your ins provider to pay once you should be able to get them to pay a second time and look at it this way you will be saving them money in the long run by avoid DM, CAD, HTN and the list goes on. There are vets on this site who can assist you in getting your ins company to over turn the denial. Know you have a right to an appeal. Do not take no for an answer. There is also a process called a peer to peer in which your MD would speak with a medical director at the ins company. A P2P could work in your favor as you would be getting it past the nursing level and then your surgeon can explain the problems you are having with the medical director and perhaps he can convince the medical director it would be in your favor to have the DS. You can ask for a peer to peer however talk to your doctor first so he can prepare. You can also insist on the P2P to be done with a surgeon who is specialized in gastric if they do not have one the ins company is required by law to contract with one out side the ins company. Most pt think if the ins company says no that is it but that is not true. You do have rights to ask for an appeal and I would in your case focus on a peer to peer review as I think if you had 2 surgeons talking they would not get hung up on BMI.
I hope this helps if it does not and I just sound like another medical person please let what I shared go in one ear and out the other as I am just like you and my intention are meant to be useful.........
To give you hope I had my ds on 2/14/12 and today I am down to 154
Donna
on 12/1/12 11:09 pm - Mesquite, TX
Donna,
Thank you for your kind words and all the info. I am praying all will work out and I will be calling insurance yet again tomorrow.
