Band over Bypass Surgery - Approved then Denied after having the revision (sorry for the long...
I had Bypass surgery Dec 2008 and weighed 371 pounds at the time. I was able to get to 190 at one time then stayed around 200ish for quite come time. During the time i was never able to eat much, became intolerant of most foods and would regurgitate most of what I would eat. In 2012 and 2013 I had both of my knees replaced due to a history of arthritis, had terrible reflux constantly, gallbladder removed and suffered with gaining some of the weight back although I barely would eat. During the last years, I go to the gym 4-5 times a week, work out as much as I can on the Eliptical or bike but still weight more than I should. In September I went back to the DRS Office to see if i had a stricture, my stoma had enlarged, etc and found i weighed 232 which is considered morbidly obese for my 5'5 frame. During the EGD i had there was no issues with my stomach except it stretched from a 9-16 in size which meant that i would and could absorb more food than I was meant to which i believe was occurring based on my eating habits and work out routine. I spoke to the Dr and he suggested to look at a revision to help with my symtoms of feeling sick all the time for years, weight gain and streteched stomach. I was advised by the DRS office i was approved for surgery on and they had clearance for me to have it. on December 7 via a phone call and email. I was asked to come in for preop Wednesday same week 12/9 for a surgery on /. Well I went in and had the revision. I am doing ok in discomfort and pain still but doing fine for most part and feel less sick than I had been and no acid reflux so far. On Saturday I received a letter in the mail addressed to my Dr and myself stating the benefit for a revsion surgery was a benefit i was eligible for under my plan. Then the second letter was opened and it stated i was denied. YES DENIDED after having the procedure. I am so beside myself and will be calling for an appeal to BCBS as well as to my Dr in the morning t9o determine how they thought I was approved. I do not have the money to pay out of pocket and only had the procedure not just to help medically but because i had met my deductible for the year so if approved the cost would be covered. The denial states i didnt show that i tried to lose weight, maintain my weight, no prescribed nutrition or exercise was documented and the DR didnt show there was a medical reason for me to have it or that the original surgery failed in some way. ALl the Dr would have had to show is my stomach pouch expanded out from 9-16 in size and that i was having symptoms and how sick i was feeling all the time and the impact for the positive the suurgery would have on me with arthitis, disc issues, migraines, etc I documented the last part n my letter but it feels like the DR must not have. HELP!!! I am at a loss want to cry but need to be strong to fight for an appeal and get through this, I deserve to have a surgery that works for me and helps me gain teh confidence, self-esteeem and be healthy so i can have the opportunity not to have additional medical issues. I am 44 now and really wanted to as I told the iinsurance extend my life span and improve my health Ideas how do i fight this for an appeal. I am scared due to the money, scared i did this and now may not be able to be treated by my dr due to coverage...I am open to any suggestions and appreciate you listening to my rambles and any support. Feeling very defeated and needing to be my fight mode on to try to win this battle.
on 12/21/15 4:18 am
So dreadfully sorry you are going through this and right after surgery that you are still recovering from. I wish you all the best with your appeal. What has the drs office told you about this? After all they are the ones who told you that you were approved. Did they have this in writing (evidence for an appeal)? I would also expect them to be aware if you needed proof of approved weight loss effort, exercise etc since weight loss surgery is their business. I would also expect them to continue treating you since they obviously have some part in this mess. It is good to hear you are gearing up for fighting mode and I truly hope it works for you. It might be worth the cost of a consult with an attorney if things do not readily start to look better. A consult would be far cheaper than footing the bill yourself. Once again I am so sorry you are going through this and I hope others post some useful info/experience to help you.
Good morning and thank you very much. I just received the letter in the mail late Saturday around 5P and havent spoken to the Drs office yet. I am going to call BCBC in a bit first then wait for the DR to open. I advised them and they knew i couldnt do the surgery unless it was covered and as stated when that call came and email saying i was approved on a Monday night for preop that Wednesday i decided to trust and didnt call the insurance myself since i have never had any issues with the office in the past and the DR did my first surgery in 2008 with the same girl working the scheduling and approvals.
Hopefully someone else has some insight on best way to go at this appeal as i truly want to cry and can only imagine what i will hear from BCBS.
I spoke to BCBS and they approved my procedure as my DR did a Peer to Peer review to clear it up. So lucky for my drs office. The insurance ignored 20 pages of my paperwork aa the medical director had moved the file and didn't place all pages back when it went to final review. Thank you all for your support. Firsthe checkup tomorrow.
Merry Christmas!!!
When i went in for my follow-up Wednesday, the Nurse was the one who fought for me with BCBS. The Medical Dr said he didnt like my letter as i didnt try hard enough and deserve to have surgery. My Drs office laid into them which was grest. How can someone be so uncompassionate to say i didnt deserve it. Good news is that it is approved now and hopefully this is the end and i have great success.
