Recieved letter of decline
on 3/7/13 6:58 am, edited 3/7/13 7:01 am
THEM- 1. There is no peri-operative or late complication of previous bariatric surgery. There are no complications such as staple line failure, obstruction, stricture, etc
My response to this- first off I cannot use my band due to extreme GERD that is worse when my band is tightened. Medications do not help. It was a failure. I have a BMI of 56 with co-morbidities.
THEM- 2. It cannot be determined that the member has the ability to adhere to the required lifestyle modifications required of the procedure and follow up per psychological assessment.
My response to this- My psych profile said I was more than capable of having this surgery. I so do not understand this!
I hope When Dr. Stewart talks to them he can explain the failure rate of the band and how there is a difference between restriction and mal-absorption. These people are ridiculous. Oh, and they informed me today that the first approval with Dr. Barker is no good because it was canceled when I started processing with Dr. Stewart. SO me changing surgeons may very well have cost me my life. I pray Dr. Stewart can get through to them. =(
If they decline me after that I am hiring a lawyer!
I'm so sorry you're going through this, but don't give up (obviously). Over the years I've seen that the more you bombard insurance companies with paperwork, and the more you push back, the better the odds that you'll eventually win the battle. They're programmed to try to spend as little as possible, and it surprises me how many people give up right away after the first denial.
Keep it up - and good luck!
on 3/7/13 10:55 pm, edited 3/9/13 3:33 pm
I have come to realize that Dr. Barker more than likely used a different coding that pretty much ruled out what would be needed for a revision. My first acceptance letter did not say "You have been accepted for revision to bariatric surgery" the word "Revision" was not in the letter. It was in my letter in the denial with Dr. Stewart. IT is all about the coding.
I will keep my head up until Tuesday and pray with every breath. Thank you Lizzie for your support.
I think that most states have an insurance board. You can file a grievance to that board after first filing a grievance directly to the insurance company. Get it all in writing and do it yourself (unless you can easily afford a lawyer) You should be able to find the information for this online. I did it in California and won my case. Good luck to you.
~Gail R~ high wt.288, surg wt 274, LW 143, CW 153, GW164
