Question:
Appeal Letter Help for Particular Hospital

Hi. My insurance (Blue Shield of CA, HMO Cobra) will cover my WLS, but the only place in California they will approve is UC San Francisco. This would be no problem except for the fact that I need a thousand more tests for them, and they say if I'm really diligent that I might get a surgery date within the year! I have been waiting and backburnered for so long, I think I'll just have to pay for this myself!! But I was wondering if there was a way to appeal the decision of a different surgery group, and VG instead of RNY as the better, safer option for me. I have already closen another place, called LAPSF and have paid the $375 consultation fee from my own pocket. The doctor there (Dr. Feng) is AMAZING and he said that he would recommend the VG as the better procedure for my situation. I have never written an appeal letter before, and I don't even know the format. Please help!    — Diana S. (posted on November 11, 2005)

November 11, 2005
Dinana, Usualy the surgeon your wanting to do the surgery or his office writes the appeal. They know what to say and the wording to use. They also know what kinds of documentation they need to send with the appeal letter in case there is any. For instance some insurance companies will require a six month dr. supervised diet documentation to prove that other methods have not worked. Most of the surgeons out there know what requirements the insurances want and can and usually are supposed to write your apeal letters for you. Everyone is different but this has been my experience. Hope I helped. Your WLS sister Jo Michalko
   — Jo_Michalko

November 12, 2005
I can't advise re: appeal, but I would be sure VG is the best surgery for you. I had VBG (Vertical Banded Gastroplasty) back in 1990 and lost very little and continued to gain after 6 months (as did 95% of the patients who had this surgery). I am not sure how the VG that is now be offered is different but I would be very, very sure before you proceed. If the surgery doesn't work for you then you are going to have 100 times more difficulty finding a surgeon to operate on you as a revision a few years down the road, plus once again feeling like a failure. I spend two years trying to figure it all out and ended up going out of state to have DS with BPD as a revision and had many complications due to all the internal scars tissue from the previous surgery. I believe the VG that is now being offered is also referred to as the mini bypass and does NOT include any malabsorption.....and remember many surgeons have spend a week learning this surgery and it is a big money maker for them and hospital. It is easy to develop a good bedside manner. Please look into the long term success of VG before you proceed, and look into how many surgeries your surgeon has performed and has he only done VG's......You may be in better hands if you find a true bariatric surgeon who does all types of surgery. I hope I am not sounding like I am preaching. I had my revision Aug 1st and was a self pay. I had to go back to surgery 3 days after first for questionable bile leak, and then were re-admitted 10 days after discharge and was in hospital for 6 weeks for a gastric leak. I will need to file for bankruptcy to pay for everything after the first surgery.....so from someone who has seen a lot of the down sides - JUST BE SURE YOU GET THE RIGHT SURGERY THE FIRST TIME! Please feel free to write back if I can help in any way. Valerie
   — *Ladybug *.

November 12, 2005
I haven't heard anything like that happening before. Did they say why they wanted you to go to that particular hospital? My husband has Blue Shield of California too, and I am waiting upon approval from them for my surgery. I want to go through Scottsdale Bariatric with one of the surgeons there. I've heard that Dr. Blackstone, Dr. Kieran, and Dr. Kohler are terrific. I haven't heard anything back from them yet, but I'm saying a prayer, crossing my fingers, anything that I can think of. I'll start adding you to my prayer list. Question, did they require that you do the six-month physician supervised diet program before they approved you? Mary-Margaret
   — Mary-Margaret

November 12, 2005
Hi Valerie, When I spoke to my surgeon, he said that VG was a good choice for larger candidates like me. He was saying that his results showed that his VG patients vs his RNY patients had the same overall weight loss minus the dumping syndrome. There were a bunch more statistics, but I really felt that he wouldn't suggest it unless he had complete faith in the results. However, I DO really need both sides of the coin... the good and the bad, and your answer has been really helpful. I will bring these questions to him and have him walk me through the decision process again. Thanks a lot! Hi Mary-Margaret! They said that they go with who ever can give them the best deal. In my case, that's UCSF. Not really sure why though... grr. I didn't have to do any supervised diets, but I've been fighting and clawing at the system for over a year. First I had one insurance, then my job changed insurances, then it was number 2 ins company. They weren't contracted with UC Davis (which was my choice at the time) so I went then with number 3, Blue Shield through my dad's work. I'm just so tired of their hoops, so I was lucky enough to get a settlement from a car accident last year, and I'm just going to use that to pay myself... it looks like that more and more. Unless by some miracle I can put together an appeal that they accept. I've got a call into LAPSF to see if they'll write one for me. Much luck to you, and you'll be in my prayers as well!
   — Diana S.

November 14, 2005
Thanks Diana....I wonder if it will be any different since my husbands insurance is a PPO? It's a shame you have to go through all that but at least you have another option. I'm positive you're going to do great! Any idea how soon you'll be able to get things really rolling? Mary-Margaret
   — Mary-Margaret

November 15, 2005
Hi Mary-Margaret, I am totally on top of this already! I am so excited. I have only to get a physical and some blood-work, and have some results sent over to my surgeon, but other than that, all the prep work is done. At least my insurance covered the testing and psyc eval that I needed beforehand. I even have a surgery date!! December 14th is my day of truth. I just feel like screaming my happiness, I can barely contain myself!! I wish you well in your journey, and I wish you have a much better time of this before-stuff than I did.
   — Diana S.

November 16, 2005
That is absolutely WONDERFUL!!! That is also the date of my 20th wedding anniversary.....we both get a present. How cool is that? Hey, if you want to keep me posted off-list, my e-mail is [email protected] Feel free to drop me a line any time you'd like!
   — Mary-Margaret