DENIED!!! HELP

I recieved my denial from BC/BS yesterday stating they will not cover a lap band due to patients non compliance of diet.  (I have had a RNY, the band was going to be place over my enlarged pouch)  I had a upper GI and EDG that both comfirmed a enlarged pouch and stoma!!  Don't know what to do or where to turn.  I was looking at the insurance prior auth and only dianosis I see are morbid obesity, DJD, GERD, and low back pain.  I also have PCOS that was not included or the enlarged pouch and stoma.  I was given the impression that an enlarged pouch and stoma was a mechanical failure not non compliance.  When I had the scoped done and the Dr spoke to me, he was pretty confident this was not going to be a problem to get covered.  So should the Dr's office resubmit it with the correct diagnosis or should I start my appeal to the insurance company? Any suggestion or help would be apprieciated! Thank you

They are mistaken.  Give them more information.

Here's "my" suggestion.......other plans may vary.....

1.  Write a detailed letter outlining your co-morbids, the test results and the fact that you were compliant (you were, right?) and that a mechanical failure will not allow you to reach the healthy goals you and your medical team feel is necessary.  Use the verbage from the OAC regarding metabollic failure if you think that will help.

2.  Have you doctor write a letter summarizing the "medical necessity" for a revision.

You submit both for a 1st level appeal.

Then ....have your surgeon conduct a peer to peer review if the appeal is denied.

Keep at it.  Don't give up!

The squeeky wheel gets the oil more times than not!

I would consider it a blessing in disguise... research the ds... don't you think Joyce?

Yikes Shele!
With my speed reading of the "Denied!!! Help" post, I totally thought there was a DS mentioned in all of those "D",s!!!  .....  Just proof that my B12 is in the toilet, right?!!!

Definitely could be a blessing in disguise...if it gives her cause to pause an do some serious research!!!

She should definitely check out www.dsfacts.com  .....

Thanks for catching that Shele!  Heaven's!  She could have mistakenly thought I was supporting some other type of revision!  NO WAY!  Been there done that and am a mess because of it!

Have a great Sunday!

Thank you both for thinking of me, but I have research the DS and decided it is not the right route for me.  I want a very low risk surgery that will give me restriction back.   This is the least risk to me and nobody in around here does DS anyway and I don't want to travel.  I have weighed all my options and this is what is best for me with my history.  Thank you

Huth,

   First of all, I COMPLETELY understand your plight. I had an RNY in 2000 and of course, gained weight due to a stretched pouch. I too researched the DS, but like you, it's not the route for me at present time, so I decided to go with the BOB (band over bypass lol).  I was denied for a revision despite the fact that I thought mechanical failure was proven, so I have decided to take my business elsewhere. Not everyone agrees with this practice, but there are many OH'rs on here that have done the same. I am heading to Mexico. PLEASE no bashing, just sharing my experience. I am set for 6/29/10 and will be paying $6500.00 with a FANTASTIC bariatric surgeon in a state of the art hospital, not a clinic. There are other options out there, please don't give up on your dream of a healthy lifestyle because an insurance company wants to give you a hard time. Of course I would file an appeal, but if that doesn't work out, there is always another way. I wish you NOTHING but the best!  

~Kells

If you had RNY and had trouble keeping weight off/keeping your pouch from stretching, what makes you think the lap band will work? It has the highest failure rate of any of the currently approved WLS surgeries, and putting a band over a bypass might just lead to more failure.

I can understand not wanting the DS if you feel it isn't for you, always go with your feelings, but the lap-band offers very poor long-term success. It is invasive, there's a piece of band in you for as long as you keep it, and you have to go for fills. If you have GERD it will make it worse. It won't reverse PCOS.

They consider an enlarged pouch and stoma diet failure, not mechanical failure, because something had to stretch it and they assume that the something was food.