Denied!!!! The battle IS NOT OVER!!!!!
I put this in my blog & I will be X-Posting this on the DS forum as well.
Got my denial letter yesterday from the insurance company (4/23/2011). I do know that they send the claims along to Medical Consultants to review. I will be calling my claims administrator in the morning regarding the "no documentation of my participation in a medically supervised diet" & fax all of that paperwork to her, and to get a copy of that determination from the Medical Consultants, that report has all of the details. The one thing that just irritates the **** out of me at the end of the letter is, yet again they state that there is NO DOCUMENTATION of me participationg in a medically supervised weight loss program??!!?? I HAND carried all of the documentation to my office visit in California with Dr. Keshishian. I have dug it all BACK OUT and I will be faxing it down to my Claims Supervisor first thing tomorrow morning!!!! UUUUUUGGGGGGGGGHHHHHHHHH ******g IRRITATING!!!! I have been on a medically supervised diet, with phentermine & monthly weigh in's well over 18 months!!!!!!!!!!!!! But in the mean time............
Here is what the insurance company says:
We fowarded your 3/24/11 request to preauthorize coverage for a revision from a failed gastric bypass to a gastric reduction/duodenal switch procedure to correct severe complications from from the previous procedure for Jamie (last name) to the medical consultant for the Alaska United Food & Commercial Workers. (a.k.a. Safeway) The consultant reviewed the documentation submitted with the current pre-authorization request and the documentation included with the previous request dated 10/25/10.
The reviewer's conclusion was that the surgery is not medically necessary. "The patient is 8 years status post Roux-en-Y gastric bypass. While her initial weight loss was very good, she has been unable to sustain that and has regained 85 pounds. The upper endoscopy identifies a healing marginal ulcer and the upper GI contrast study shows normal past gastric bypass anatomy. There is no documentation of attempts at treatment of the mariginal ulcer or that her low vitamin D level is refractory to conventional supplemental treatment. Finally, there is no documentation of this patient's participation in a medically supervised weight loss program. The avaliable documentation does not support that revisional bariatric surgery is medically necessary for this patient."
Consequently, we will not be about to allow benefits toward the proposed revision of the 2002 gastric bypass.
Please let me know if you have any questions, or if I can be of further assistance.
(Lady's name)
Claims Supervisor.
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
Thank YOU!!!! Tomorrow is a new day & I have a game plan to get me started, at least!!!!
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
