Never mind - they approved today!!!
Thanks for responding Gary. I actually left you a message at your web site. I filed a grievance today and carefully read their policy and my certificate of coverage. They both say " coverage is limited to one bariatric surgery per lifetime unless medically/clinically necessary to correct or reverse complications from a previous bariatric procedure. " Both times my denial simply stated that I do not meet their policy criteria - coverage is limited to one bariatric surgery per lifetime, and ignore the second half of the statement of policy. I have massive reflux disease that is documented in 4 EGD tests and a Bravo test. They offer to remove the band (my first surgery 14 years ago) that was unsucessful and causing the reflux disease. But they will not convert to the RNY. My doctor has written to them stating studies saying that removing the band and even performing a Nissen will NOT be effective in obese patients, and the RNY is proven to be much more effective. This is not a little heartburn. It really is massive and I am on large amounts of RX, have slept sitting up for 2 years, and the acid is litterly erroding my throat. The BRAVO test read 75.7 and normal is under 14.72
So in summary, they are willing to pay for a surgery, but not one that will do any good. I don't think they even read his letter because it just doesn't make any sense what they are saying. In my grievance I reviewed my history, their criteria for WLS and that they paid for this eval and I meet all the criteria (included and checked each item off). FYI-My BMI is 47. But I guess they didn't know previously that I had a prior surgery that they could deny me with. They did not pay for the previous surgery. I also included EGD test results and recommendations by a different dr. than my surgeon, my surgeon's thorough explanation and appeal why only a RNY would be effective, their policy and my Certificate of Coverage with the bariatric surgery section highlighted, and my reasoning why I believe I should be allowed to have the RNY. I summarized everything in my letter plus attached it.
Did I cover everything? Would you recommend anything else? Their grievance procedure outlines they need to reply withint 15 days.
THANKS GARY!!
Nancy
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