OMG denied AGAIN! Desperate and need HELP!!!!

Hello,

I desperately need HELP! I was denied again by BC/BS and I have no idea what I am doing WRONG! In my first appeal letter I elaborated on my medical history, why the revision surgery is a medical necessity and why I disagreed with the denial.  I even went into how cost effective it would be to approve the revision surgery.  Because in the long run, the insurance company will end up paying much more on my care as my weight increases and it will increase without the revision surgery.

According to BC/BS there is nothing wrong with my pouch so a revision is not necessary.  Their decision is based on an endoscopy I had more than a year ago and I have gained so much weight in the last year.  The pouch may not have changed, but the stoma must be larger. OMG! OMG! OMG! This is driving me NUTS!

This time around I really don't know what to do!  I will not give up and will continue to fight this.  Is there anyone willing to share an appeal letter that was successful for them? I REALLY REALLY REALLY need help/advice!

Thanks!

Y.

Get another endoscopy as well as an Upper GI which is NOT performed NPO. Something is clearly wrong.

Also, you may want to look into self pay for revision.  After fighting with my insurance and them telling me they would approve the revision, they disapproved it AGAIN with the caveat to come back in three to six months.  After reviewing the financials, my surgeon and the hospital I am using are charging me PRECISELY what my out of pocket expense would have been anyway.  Take a look at dollars and cents/sense if you get nowhere with your insurance.

Thank you very much for responding!  Yes, I am going to have another Upper GI done and I am not giving up!  This whole process started a little more than a year ago and I can't believe my doctor didn't request a new Upper GI before he submitted my paperwork to the insurance company.  it didn't even occur to me to  request a new Upper GI because of all the other requirements I was trying to fulfill. 

If BC/BS denies me again, I will think about paying out of pocket.

I agree you need to send them current test results and also ask them what exactly they want to show the revision is needed. Appeals can be a pain but sometimes they do work. Don't give up yet, wishing you the best!

Yes, I am going to have a new Upper GI done because over the last year I have fulfilled all of the other requirements needed by BC/BS.  This process is a royal pain in the neck, but I will not give up! Thanks for responding!

I agree new EGD is necessary. My Dr. requested cpt 44120 due to pouch extension stoma size nausea/vomiting,diarr. BC/BS approved and added that this code did not require pre authorization. Not sure if u are having same medical issues, but it s worth discussing with your doctor. Good Luck

Thanks for the code and I will discuss it with my doctor.  Everything I eat goes right through me and I am ALWAYS hungry!  I am nauseous all the time along with everything else I am experiencing and my medical issues, I have to keep fighting.

Thanks for repsonding!

check this out they have a letter here.

http://www.obesityhelp.com/forums/revision/4548112/If-your-h aving-Lap-Band-problems/

It's geared for lap band failure but, has losts of useful info on documenting too.

I tried to look at the site you sent me, but it won't allow me to.  Thank you for responding!

You may need to join a group.  I'm not sure if it's okay with OH's current TOS to tell you the name of groups anymore but if you go to the aqua top band and select groups, it begins with Failed.