Waiting for Appeal to be processed
Well, insurance authorization for my RNY to DS was denied and I have since submitted an appeal. This time, I was sure to outline line- for-line how my case meets insurance's definition of medical necessity:
- Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch (documented by upper gastrointestinal examination or endoscopy) - Both my radiologist and surgeon reviewed the UGI results. My radiologist saying my pouch was mildly to moderately dilated. My surgeon referring to it as a large dilated pouch.
- The initial procedure was successful in inducing weight loss prior to dilation - I lost down to a 22.8 BMI and kept my BMI under 25 for 3.5 years. My BMI is currently 36.
- Patient has been compliant with a prescribed nutrition and exercise program. - I submitted records of nutritionist appointments and weight loss program participation and well as health club memberships and purchase of a home treadmill.
So, those are the 3 requirement per my Member benefit handbook and I think I gave documentation of meeting all three. I'm still so nervous that it will be denied a 2nd time. I'm also concerned that I have other things that insurance isn't even looking for as problems. In the last year, about 30 minutes after I eat, I have diarrhea (sorry, gross, I know) every time. Could everything be passing through that quickly and that's why I seem to be hungry all the time? It's troubling to think this could be another lifelong problem - or that the weight is going to get worse that it ever was before the first RNY.
I know I've seen a couple people referring to a law firm that helps represent clients against insurance denials. Can anyone point me to their website or possibly give me more details on how that may work?
Thanks all!
