Revision Denied- I lost enough weight w/1st surgery. Even though my BMI is still at 40
Received a denial letter from BSBC FEP of CA for Revision surgery from RNY to DS yesterday. Feeling a little overwhelmed with having to write an appeal letter. Not sure where to start. Any suggestions on how to respond? Anyone else ever been denied because they lost enough weight with the first surgery?
Thanks in advance,
Carla
I was not because of insufficient weight loss, but weight regain. I started this process with my surgeon in April of this year, and yesterday I was finally approved! I have surgery on Monday.
A few things I would suggest, one is are you sure that your insurance will even cover a DS? Tricare will not period, not for the first surgery nor a revision. Check and see if they will cover in normal situations. If they will no cover a DS go for a distal or Erny surgery. That is the step closest to the RNY and DS.
Second, if possible,have your surgeons office insurance person do the request appeals. My surgeons insurance rep was fantastic. She did all the request and appeal letters and kept up with the insurance company. I think that helped in the total process since I did have a surgeon who agreed I needed it.
Letters letters letters.. as many as you can get from dr's that agree weight loss would solve the physical issues you are suffering from.. Include as many as you can, and have the surgeon's insurance office or yourself include them in all appeals. Even go online and get / print out medical papers on the success rate of revisions. And how your different conditions weight related effect you now and would be a positive outcome with the revision. Just Google your conditions and revision weight loss too. You will come up with a ton of medical papers written on each that you can print out.
In your appeal letter, if you have to do it yourself, keep to facts, no emotion.. just plain medical facts backed up with Dr. notes or medical papers (or both).
Keep track of dates- when you speak to anyone from your insurance or surgeons office, what date appeals were sent, when you received an answer and what it was and why.
And lastly don't give up. Even if you have to start the whole process again after you have lost all appeal possibilities. Just keep at it. It took me 3 denials, a Peer to Peer with my surgeon and the insurance company, and then another appeal before they agreed. It was a uphill battle. i was getting ready if this last appeal was still denied, to start the whole process from the first request again. Just never give up.
