My vsg revision appeal letters - in case they might help someone else

[brittu 42]

I have been fighting the longest revision appeal in the history of appeals (about 14 months now). I figured all that work ought not go to waste. So I've posted the letters on a blog in case it helps anyone.

I had a lap band that failed. I eventually won the fight to get it taken out and am still fighting for coverage for my revision to a VSG. My insurer is Federal BCBS and my appeal is now at the OPM in Washington, DC.

My latest letter is a summary of all (and I do mean all) of the arguments for medical necessity and references to a dozen or so studies that prove my points.

Here's the link:

http://vsgappeal.blogspot.com/2010/07/summary-appeal-letter-studies-and.html

If this doesn't work it's on to a lawsuit. Looking just at the details in the latest letter I don't think they have a denial leg to stand on and I'm pretty sure I'll win. Just hate to waste the time and taxpayer dollars to take it that far. But I'm pretty motivated - they have to get this fixed so it doesn't happen to other people.

Britt

[mila1013 0]

Britt

thanks for posting this, I will be in the same boat as you band removed, last week, bmi doesn't qualify, geesh it is a revision, after a while this whole thing is just foolishness, what can we do but to keep appealing, I should have my denial letter next week.....thanks again....

Mila

[brittu 42]

You fight them, Mila. Only a few insurance companies insist on the patient regaining all their weight before a revision. Most have policies that consider a revision a continuation of care and you can overturn the denial with a little work.

Best of luck! The sleeve is worth it.

Britt

[kisses4k 0]

Oh Britt - this is what I'm looking for. I went to my doctor today for my consultation and they told me that BCBS FEP doesn't cover the sleeve. This was after they told us at the seminar that if we had BCBS FEP that we have the "golden ticket". Some "goldern ticket"... I have a BMI of 45 and co-morbidities so I can't understand why they wouldn't cover it. I'm still going thru all the testing, etc and making the dr's office submit. After that I'll see.

I wish you luck and I'll be watching to see what happens

[FitatFifty 11]

Britt

Big thank you for posting your letter on your blog. I used your format with my appeal letter (5 pages of argument and research as to why SG is not investigational) and was successful getting the denial overturned. My surgeon also wrote a letter stating sleeve was medically necessary because I have celiac sprue. It was a one-two punch!

Thanks again, and I wish you success in your efforts!

Fit