My revision appeal letters - in case they might be useful

I have been fighting the longest revision appeal in the history of appeals (about 14 months now). I figured all that work ought not go to waste. So I've posted the letters on a blog in case it helps anyone.

I had a lap band that failed. I eventually won the fight to get it taken out and am still fighting for coverage for my revision to a VSG. My insurer is Federal BCBS and my appeal is now at the OPM in Washington, DC.

My latest letter is a summary of all (and I do mean all) of the arguments for medical necessity and references to a dozen or so studies that prove my points.

Here's the link:
http://vsgappeal.blogspot.com/2010/07/summary-appeal-letter- studies-and.html

If this doesn't work it's on to a lawsuit. Looking just at the details in the latest letter I don't think they have a denial leg to stand on and I'm pretty sure I'll win. Just hat to waste the time and taxpayer dollars to take it that far. But I'm pretty motivated - they have to get this fixed so it doesn't happen to other people.

Britt

Thanks for posting this. I am in the process of fighting for my revision from lap band to DS. I have filed my external appeal and am waiting for the final decision. I know when I was trying to find insurance appeal information it was fustrating so it is helpful of you to post your information.

Good luck with your appeal!

Ann-Marie

Great letter. I hope it works. I have just be told I have to do a 3 month or 6 month weight loss program to even have them look at my case. The surgeon's office is going along with it. I had my band removed last August because of erosion. At the time I only had 45 lbs to lose and they thought it would happen on it own, but after getting parvo virus infection and having to take steriods I started gaining weight. I jumped thru the hoops for my surgeon and then I get a letter today asking for a weight loss program. And no body can tell me why!!!
I wish I could find a lawyer like yours!

zetabeans, I think you might not getting good information. You don't have to do weight loss program for a revision. For most insurance companies, the standards in revision are related to the cause of the problem. If the cause was failure of the original surgery (erosion for you) then the revision to a new surgery is considered continuity of care. You can see all the details that might help you in the letter I posted on my blog in June.

You can actually have the same lawyer I had, just check out obesitylaw dot com. Walter and Kelley work with you over the phone and their fees are pretty low compared to most attorneys. . They actually thought I'd done a good job on my first round of the appeal and didn't step in until letter. In fact, all the letters posted on my blog are ones I've written. My local surgeon offered me a job writing letters for him :-). I didn't post the letter the Lindstrom's wrote for me, I didn't think that was fair to them since the arrangement was with me. But the stuff I wrote and reasearched, I felt that might be useful to others.

So sorry to hear about your troubles. You'll be so happy with your sleeve. It's so much better than the band.

Great letter....I am in the process of seeking a revision...I am on month 3 of my supervised diet.   

So were you told upfront that you would have to do the 3 month or after you submitted for approval?

Hey Candie33 it was good seeing you today. I hope to see you soon again

I don't get why you're on a supervised diet for a revision. For most insurance companies, a revision is considered continuity of care and the original requirements for WLS don't apply. I'd definitely check the policy if I was you. What's your insurance company? I can check it for you too.