Need Appeal help

I need to know if anyone might have an Appeal letter that was wrote to OPM. I have BC/BS Texas Federal Plan and I might need  some type of document to go by to appeal my case with OPM. My Dr. submitted with the codes the pre-determination letter for me to have Lap Band revision to RNY due to a lot of proven complications. I called the Insurance Company this afternoon and well she made me feel like she was not being honset and put the call on hold so she could go and look up this information, well the last time Ic alled no one treated me like that. She then went on to say that well they have only had the information for the last 8 1/2 days and it takes longer and how a Dr. and a nurse reads each pre-determination etc she then asked me when my procedure date was and I told her I was not yet given one that the Dr. needed to do get the authorization first. Heck maybe I was wrong but how do I know? If I am denied then I will appeal with OPM and I ahve plenty of fire for the furnace sort to speak (documents). Hope some can help me out here. Thanks

I am so sorry to hear all the trouble you are having. I have BCBS Fed and did not have this issue. I am not sure why you are. My surgeon saw me in April, I needed the RNY revision with a pouch shrinking. He called me in a week with a surgery date and approval. I would ask the Dr to recheck what codes he is using. One number off spells doom. Can you site back issues, rashes as well as diabetes if you suffer from it? As for a Dr reading a predetermination it takes a day or so. Usually they tell you right after they check you. Hope that something works in your favor.

Thanks NeeNee..I have no idea what is taking them so long to approve this. The doctors office is going to call them tomorrow morning to find out what the situation is. She said that the code she used was for Mechanical failure and also a Hiatal hernia that I never knew I had. She said that with the Lap Band and the hernia that the Band has to go for it causes distress on the esophagus like mine did. She aslo listed that this was the third time in two years that this has happened, she submitted all my UGI report findings and tehre are like 8 UGI's since I wasbanded four years ago. I was also told that all of this will cause my esophagus to have a lifetime of problems that it is not good. She also listed that the Dr. had been conservitly treating me for two years with these problems and the other, like the constant vomiting, sliming, the narrowing of the lower part of the esophagus and everythng else so in a way I ffel good about the end results but then after today I did not think so much. I am praying that tomorrow will be the answer day and that it will be a yes approval for me. Thanks for answering my message.
Roxy

Ah, I see. I am still shocked with all the findings that it is taking so long. Have you considered the RNY? That is what I had. In a year I had gone from 350 to 197 lbs. I then got pregnant. (oops! ) lol And a week ago had a revision to reclaim my pouch. My weight loss is back on track. I will keep praying that they accept for you soon!!!!!

Nee Nee, yes my Dr. did submit for the revision from lap band to RNY, he also does the sleeve but I don't feel good about having half of my stomach cut away never to return. I wanted the RNY all along but four years ago I was afraid and now I am not. Thanks for the prayers, only people like us know how much prayers are needed and accepted.

Roxy

Anytime. Has he told you what to expect when you wake up from surgery? The tubes you will have and all?

I don't know how helpful it will be as I was appealing a VSG decision, but you're welcome to pull anything you might find helpful out of my appeal letter (it worked, I won the appeal).

Was this an OPM appeal? I am also appealing to OPM but my appeal is for ACTII

What's OPM and ACTII?  Mine was a BCBS appeal.

ACTII is misplaced copy, Sorry.
But OPM is Office of Personnel Management.  Like one big HR department for all Federal employees.
I appealed my Carefirst BCBS denial and the denial was upheld. So now I have to appeal to OPM.