Insurance Denial

Oh my gosh! I am so glad I stumbled across this portion of OH.com. Here is my story... I had an open RNY in Lubbock, Texas by Dr Ted Scott 5 years ago. At that time I weighed 242. In the beginning I lost very fast. My goal was to be at 142-150. I lost down to 169 in the first year and then suddenly stopped. I began to be able to eat more than I could at first. Fearing that I had stretched my pouch, I carefully controled everything that I put in my mouth, I practiced the rules and exercised. Nothing else came off and I pretty much stayed at that weight 169-175 for the next three years. I noticed my weight yo yoing for the next year or so. I could eat almost normally again. I began experiencing reflux. Knowing that I was not supposed to have gastric juices in the upper pouch, I suspected that I had a problem. Dr. Scott is no longer in Lubbock, so I saw the doctor who is now doing surgery in his place. Dr. Eldo Freeza. He suspected staple line disruption. I was sent in for several tests. It was discovered that I still had H Pylori and there was an opening from the pouch to the old stomach. (I was never transected at my first surgery) I am now up to 189 lbs. With that information we went to my insurance company, United Healthcare and asked to be approved for a revision. Well...guess what. They have denied the surgery stating that because I was not morbidly obese that I did not qualify for a revision under my policy. I guess I have to So here I am pleaing for sample apeal letters and any ammunition you all may have to try to get this procedure approved. Thank you so much information you may have so I can get this appeal letter written. Kelly

Hi, I had the same problem. I will be happy to email you a copy of my appeal letter. My appeal was won within 3 days. Took me forever to get all the info to send with it. My primary and surgeon both wrote letters too. Just had my revision October 11, 2005. My consultation for the revision was October 2004. Drop me your email and I'll send you a copy of my appeal letter. My primary told me it was excellent and I should be a lawyer. Hang in there. Someone told me once they expect you to accept their answers and walk away. You have to keep fighting and fighting. Use all your appeals. Look forward to hearing from you. Never give up.

I appealed with United Health Care and won! No date scheduled yet.

Great, I was approved and now the surgeon that I was working with, Dr Eldo Freeza. He will no longer do the RNY surgery due to a hand injury that prevents him from doing fine stitching. I was getting a little discouraged with the office staff. They would not return my calls and would not follow up with insurance matters. They did not even bother to tell me he would no longer do the surgery. I found out by calling the office. THANK YOU! I have decided to use Dr. Kenneth Warnock out of Wichita Falls, Tx. I have several friends that have used him and he is in my network. He has performed many revisions.