XP- Appeal Denied
I received my denial letter in yesterday mail. Here is what it states:
(And, yes, I HAVE already mailed off a request for a hearing.... The board meets quarterly. Next meeting is end of October)
Dear Mrs. ________:
The Appeals Committee for (my insurance company) recently met to consider your request for coverage of gastric bypass revision surgery/duodenal switch procedure. The Committee relied on the medical review information presented and took action to uphold the denial of coverage of these procedures. This is based on the Plan’s Exclusions and Limitations, listed on pages 36 and 37, which state:
Services which are primarily for weight-loss (except surgery for morbid obesity which has received prior authorization from the Administrative Office); and
Any medical services which are not medically necessary (see page 71).
The January 2010 Summary Plan Description is enclosed for your reference. If you apply for benefits and are ruled ineligible, or if you did not receive the full amount of benefits to which you are entitled, or if you are otherwise adversely affected by any action of the Trustees, you have the right to appeal to and request the Board of Trustees to conduct a hearing in the matter. Such a request must be in writing and submitted to the Trust’s Administration Office within one hundred and eighty (180) days after the date of mailing to you of notification of such ruling or decision. The full Board will then conduct a hearing at which you will be entitled to present your position and any evidence in support thereof. You may be represented at any such hearing by attorney or by any other representative of your choosing. Thereafter, the Trustees will issue a written decision reaffirming, modifying or setting aside the former action.
Sincerely, Blah Blah Blah
-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**
You have been in it for the long haul. Bless your heart!!! I know your pain. I was denied for my VSG from BCBS Federal. I was denied and I appealled and it was denied again. I decided to do self pay. Not everyone can do that. Especially now how the economy is.
I know that you are not a quiter. I wish you the very best that you will get approved!!!
Hugs and Prayers coming your way.
Virgie Tschirhart
Lap Band - 2008, Sleeve - 2009, RYN - 2017
Started Program Weight July 13, 2017 - 194.2
Before Surgery Weight December 27, 2017 - 185.0
Current Weight - February 2018 - 161.0
Thank YOU for the hugs and prayers!!!! They are much needed and VERY APPRECIATED!!!!!
Believe me, I have looked into self-pay. I know how much it is. I have not exhausted my appeals, so I plug on!!!!!!
-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**
Sophia,
Thank you SO MUCH for the continued support!!!! This time last year you were struggling with insurance and appeals to get your revision. I am STILL struggling, but with all of the positive help, hugs, and encouragement, I KEEP GOING!!!!!!!!
The Board meets quarterly -- Next meeting is end of October
-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**
Hislady,
Thank YOU SO MUCH!!!!! You are added!!!! I have requested the next step, which is a hearing. So, onward I go!!!!!
-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**
They often just don't want to spend money! They think if they deny you, you will think it's a TRUE NO and won't ask again.
APPEAL!!!
246 in Dec 2008 before banded 1/28/09 at 215 lbs, band crapped 9/09 at 170 lbs and struggled with it and regained to 203 revised to bypass on 8/1/11 and am very happy.
Cheryl,
Oh, believe me, I will not give up at this point!!!! My next step in the process is a hearing, which I have already mailed off my request for, certified, return receipt. If the insurance company would have paid the first time I applied, 2 years ago....... they would be saving money at this point, instead of spending it. Cause they would have had the surgery PAID FOR!!!!! Dumbasses!!!!!
I WILL NOT GIVE UP!!!!!!!
-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**
