Got my denial letter...unbelievable...

Got home from vacation yesterday...my denial letter from BCBS was waiting for me. Guess what it said...The request for a repeat bariatric procedure was not approved based on medical policy G-24 (which I will be requesting a copy of)...and then it says..."The patient had a rouy en Y bypass and lost weight successfully but has regained weight." WRONG!!!! I believe the definition of successful weight lose after WLS would be to have at least lost 55% of my excess weight. I have not been able to do so because of my dilated pouch and stoma...i.e. I need a revision. I have not regained weight. I have worked hard to maintain my weight for the past 2 years. All my doctors notes show my weight...last appt. in Ohio 335, May 2004...first appt. with surgeon here in Nov. 2004 337. I have some PCP notes in Ohio and here in between if I have to pull them out but come on like I lost down to goal and gained back up in 6 months. And by the way the 55% lost would still leave me at a BMI of over 45...so where 55% would technically be consider success...in order to be healthy and reduce my risks I need to lose more, and I know I could if I didn't have the problems I did. To me I should be able to call BCBS and tell them you didn't read file completely, I shouldn't have to appeal....you should have never made the decision you did!!!! I did that before when Cigna denied my garments, they said I could get them in network, I called them and said no I couldn't that I called the company they suggested and they could no supply me with what the doctor specified so they needed to overturn their original decision...and they did! Sarah Margaret

Sarah, Please see under "Constance Becker", I did a reply to you on that question from her and you also did a reply there. Hope it is helpful, and if you need to contact me please contact me any time, I'll try to answer all questions

Thank you, I got your response. Unfortunately with my other health conditions I don't feel I can switch to a new surgeon or medical facility at this time, nor do I have the money to travel or pay anything out of pocket. I firmly believe that if my policy says that BCBS covers the treatment of morbid obesity than THEY will pay for my revision come hell or high water. I have fought 2 other insurances for my other medical needs and I have come too far with this process to stop the fight now. BCBS didn't pay for my first surgery so they owe me at least a revision if their policy is only 1 procedure....

When I read this and the more I read about you and bcbs I have to look and see if this is one post that I had wrote before maybe we can help each other. thank you so much I was so hoping that a revision was a start of a new life, because of so many med problem when I found the staple line break down I thought that they would fix it and mabe I could get some of my med problems behind me.

I do hope you are going to appeal! That is soooo rediculous! Good luck and God bless hon!

I have only yet begun to fight!!!! My only limitation is that BCBS typically doesn't want to talk to the patient only the provider...well I'm the one who knows my history best...and correctly!!! And isn't it funny how in the end the financial responsible is mine and the authorization responsiblity is mine....but no one wants to talk to ME!!! Sarah

I am sorry that you are going through this. How can they not think that this surgery IS NOT medically necessary? You have had two mini strokes for goodness sakes and you have other co-morbities. I had my revision done this year (March 2nd). I was a little nervous when they sent my paper work to the insurance company because I had heard Aetna can be a pain to deal with. I did everything the insurance coordinator told me to do to get approved (the 3 month supervised diet, nutrionist visit and I kept an exercise log). Thank goodness I was approved on the 1st go around. I wish you luck in dealing with the surgeon's office and BCBS. Keep the faith and take care. MJ

Hi Sarah.... I had my revision from vbg 8/98 to rny 8/04 and for me I had BCBS and had an approval within 2 weeks... I know for me I kept all my records when I was dilated and had all the pics and my new surgeon did a scope and said the ring I had was way to big for my stomach and all the scar tissue didnt help either.... Good luck I know this is hard battle to fight but so worth it in the end.... They really should approve this but let your surgeon fight it for you they know how to word things and what to say... good luck

Actually, my surgeon's office isn't being very helpful at all despite how much it seems that BCBS made a rushed and very incorrect decision. They could simply do a peer to peer review at this point and BCBS said they gave them the phone number for it when they called with the denial, surgeons office said they could not do anything until they get their letter which they claim they haven't gotten. So I faxed them mine, with the additional informational I got from BCBS, policy G24, and my records from Ohio. Right as I was faxing them the nurse called me and said the surgeon's thought an option for me would be to pay out of pocket for my surgeon and try to get reimbursed later. I said why don't you take a look at my fax and see how strong my case will be...I don't have money to pay for my surgery. Then I called BCBS myself and got the peer number for her and e-mailed to my surgeon directly with what I wanted highlighted from my chart...and said she could mention other things she felt would help. I have to make sure she remembers my case and the facts of it...she at one point accused me of regaining my weight....

I had to get a lawyer for BCBS. The person who said they paid for her surgery in two weeks .....Well, that is when BCBS was very easy to pay. Now they won't pay for anything. My insuracne company does have a revision policy but they still won't pay. I did lose almost 50%. My policy states they will pay if stoma reupturing, BMI 35 with co-morbidities (which I do have) or BMI of 40 (which I do have). I hired Gary Viscio and we will see how that works. It has been a little over a month and I haven't heard anything yet from him, but I have been trying to reach him.