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Denied then straight to Peer-to-Peer

Lauran

By Lauran, in Insurance & Financing

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Lauran    0

Lauran
Posted

Soooo...as some of you may know, my papework was submitted last week for VSG. The insurance coordinator at my WLS practice told me that it would be about a week before I heard anything back.

Well i called today and was told that I had been denied based on the surgery still being considered investigational (big surprise). Then I was told that my surgeon had already scheduled a peer-to-peer for Friday (tomorrow).

Is this a good thing, or a bad thing? Is this usually how it goes? Somebody help me out here...I'm confused...

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6kiddos    18

6kiddos
Posted

I am not sure about the VSG, but when my cardiologist wanted to do a Nuclear Stress Test (based on TERRIBLE family history with my brother having a MAJOR heart attack at 40) she did a peer to peer review also. It was approved within the day. I would think on the VSG this would be a good thing. =)

What is your ins? I am waiting on Aetna. waiting...waiting...ugh.

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peatie    4

peatie
Posted

I don't have experience, but i hear peer-to-peer is a good thing b/c the Dr can specifically talk up your case. Good luck!!

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NikiS    31

NikiS
Posted

Hi Lauran. I have BCBS too and was told when I met with the surgeon that BCBS tends to deny sleeve requests because it hasn't been around that long. He also said that if that were to happen, he would have a peer-to-peer and would be able to speak with a rep from BCBS, talk about my case and my specific medical history. He said in instances like this, about 85% of the time it is approved but BCBS will requests that in a year or so, the patient has Part II of the process which will be gastric bypass. I was all ready to give the surgeon my rebuttal but he answered my questions before I asked...no, not all patients opt to have the bypass after having the sleeve. Whew...

Anyway, I hope this helps. Please keep us posted. At the end of this month I have my psych eval and meet with the nutritionist. On Nov. 9th I take my class and my info will be submitted to BCBS so it's quite possible I'll soon be faced with this very thing. No worries...we're winners so stay positive and be encouraged!!

Have a great day,

Niki

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Go To Topic Listing Insurance & Financing

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      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
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    • Alisa_S

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      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
      Soooo I am coming to a realization
      of something and I'm not sure what to do about it. For years the only thing I've enjoyed is eating. We rarely do anything or go anywhere and if we do it always includes food. Family comes over? Big family dinner! Go camping? Food! Take a short ride or trip? Food! Holiday? Food! Go out of town for a Dr appointment? Food! When we go to a new town we don't look for any attractions, we look for restaurants we haven't been to. Heck, I look forward to getting off work because that means it's almost supper time. Now that I'm drinking these pre-op shakes for breakfast, lunch, and supper I have nothing to look forward to.  And once I have surgery on June 11th it'll be more of the same shakes. Even after pureed stage, soft food stage, and finally regular food stage, it's going to be a drastic change for the rest of my life. I'm giving up the one thing that really brings me joy. Eating. How do you cope with that? What do you do to fill that void? Wow. Now I'm sad.
      · 1 reply
      1. summerseeker

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