Insurance Issues
Has anyone here managed to get Tricare approve a revision since they changed to being managed by United Health. My surgeon is having a ***** of a time and I desperately need to have a revision. I have been disapproved, then disapproved even in a peer to peer conference. Now the insurance manager is trying for an immediate reconsideration.
Well lets see:
#1 with different surgeon was "not medically necessary" haa haa
#1 with the new surgeon - to me was not medically necessary and a one WLS per lifetime.-- They did not pay for the first surgery, so I still fall in the ruling of one per lifetime- they didn't pay for the first one at all.
#2 they will only provide revision surgery complications or failure of original surgery, if the original surgery was done with a network provider and they paid for it. They didn't pay for it, nor was it in network, but they have already paid for WLS surgery complications with an in network surgeon. It was a hernia not a big issue.
#3 not medically necessary. I have been under the care and monitoring of a dietitian regularly for nearly 2 years, I have a RMR of 1400 which is medically considered extremely low. You have to consume less than 900 calories a day to even lose half a lb per week.
I have SEVERE migraines.. that have gotten consistently worse as I have gained weight.
I already had to have my right knee replaced and without revision surgery I will have to have the left one done soon. This, along with a degenerative disc disease in my neck, and muscular injury in my left Trapazoid. Make it quite difficult for most exercise though I do walk, pay for it, but still do it.
Those are my main reasons for requesting a revision. I don't really want to get skinny as much as stop these migraines and NOT have to go through another knee replacement which was by far the worst surgery I have ever had.
The insurance company got a lot of different reasons for the denial . But the main reasons, the only reasons that have any ground to stand on, the original surgery was not done by a network provider and they will not cover any issues regarding the WLS because of that -( even thought they already have)
And not medically necessary.
I will definitely give credit to Dr. Chae's insurance coordinator and even Dr. Chae for the attempts but it doesn't seem to help. Christine, the insurance coordinator is doing one more urgent appeal for the denial but I cannot see that being any different from the answers so far, especially since the peer to peer was not successful.
I think my next step will be a long letter, my medical records and some formal medical papers published regarding the negative effects of obesity and migraine, and show strong the relationship between the two is. I have been treated for the migraines now for 4 years, and am now up to 39 injections in and around my face, head and neck every three months and home injections of three injections I do myself each month as the breakthrough ones come each week. I am at the end of my rope between them and the left knee going bad. Any suggestions would be awesome!
I hate that there is some person who makes all these insurance decisions, about me, that doesn't even know me, has that ability to determine whether my personal doctor knows what he is talking about in regard to my health!
