Appeal ready - want to give me feedback?

Hi all,

Well thanks to the great help from folks on the boards, I've got my appeal letter ready to ship off to BCBS. Anyone want to take a look? Offer me some advice? I've posted it here:

http://vsgappeal.blogspot.com/2009/06/introduction.html

...and would love to get your in feedback.

Thanks,
Britt

(forgive the multiple posts, didn't realize there was a better spot for mine here in the insurance section) 

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Just wanted to say... good luck with your appeal for VSG.  I have Anthem BC of CA PPO and they denied me 3 times for VSG as did the CDI...apparently VSG is still too "new" and considered invesitgational.

Prepare yourself for a very long ride.... it's mentally challenging but as long as you are ready for the fight... APPEAL!

Best  wishes...

I don't think that your insurance can be forced to pay for another WLS when you don't meet NIH criteria for WLS: BMI > 40 w/o comorbids and BMI >35 with comorbids. Medicare and most insurance companies require the same things for virgin WLS and revisions. I agree that they should either take out your failed band or repair the one you have but I think you'd have a hard time getting them to pay for another surgery and a VSG at that. I think most insurance companies still consider the VSG investigational (Medicare does too) and will cover it if you show you have medical reasons you can't get a different WLS like RNY or DS. If you do file the appeal, you have, I think you should just stick to the facts: i.e medical records showing mechanical failure, medical records showing our returned comorbids, studies showing you can't keep a failed band in/ failure rates of the band, consults you've had with bariatric surgeon and their recommendations stuff like that. I don't think you should keep the rhetorical questions in. Just my opinion. You may get them to pay but I would be surprised if they did. If you wanted to get a revision without your BMI being at least 35 with comorbids you may be stuck self paying for the revision. 

Thanks everyone for all your great advice. I made quite a few edits before finally sending it off today. No matter what happens now I'll know I did the best I could to fight for coverage.

Sorry about the TOS warning. It was my first blog and the automated checking flagged it for review. It's all fine now and readers shouldn't get that warning.

I reposted the final versions of the appeal request and the appendix on why VSG should not be considered investigational. What Teresa had posted on her blog was really helpful for me as were other posts I found. I'll leave the blog up just in case someone else finds anything there worth cutting and pasting for their own pre-auth submission or appeal.

Britt