Hey Everyone,

About a week ago, I was denied by Highmark BCBS for the sleeve based on it not being medically necessary and appropriate. My BMI is 36.4 with associated Hypertension and Type 2 Diabetes Mellitus. My surgeon did a peer-to-peer review this week but got no where with the physician on the review committee. Based on the fact that the peer review didnt make any progress, what are the chances that my appeal letter will have the denial overturned? I am kind of bummed because I think my chances are not so good now.

Thanks

Lisa

Hey Bananasleever

I just got home from the gym and saw your posting from yesterday. I wanted to reply quickly now to say I will write a longer post today about how I approached my appeal that might help you but right now I am off to the shower.Lol Tasherie is correct, ASMBS ( American Society of Metabolic and Bariatric Surgery) www.asmbs.org is a great resource. I used their updated posifion paper Sept. 2011 I believe on the sleeve as part of my appeal letter as well.

:bigear: I know that I am going to have to appeal so I would LOVE LOVE LOVE to hear how you approached your appeal and finally got approved :blush5:

This is how my appeals process went with Highmark BCBS. Hopefully some of this will help you prepare to appeal if needed. After being denied the 1^st time in August 2011 for the sleeve by Highmark because my bmi was below 50 and they considered my request for surgery not “medically necessary”, I began my research to refute their medical policy concerning the VSG as the first surgery in a two-stage procedure for individuals they consider “severely-morbidly obese” +50bmi. What I found was that compared to current standard practices and commonly accepted opinion within the bariatric surgical community, their policy is really outdated. Thus the position statement update, by the ASMBA supporting VSG as a single stage primary procedure. I also had no difficulty finding medical article after medical article concluding the success of vsg for lower bmi patients.

In terms of an appeal I feel the fact that Highmark does cover the VSG, albeit only for high bmi patients, is still in your favor because you have a basis for arguing that the 50bmi is an arbitrary number based on current medical data. I proceeded through 2 internal appeals with Highmark which were of course denied before moving on to an external appeal. This involved an Independent Review Organization (IRO). Basically your case is sent out to a panel of impartial professionals who review everything from both sides to make a final determination. If they rule in your favor, Highmark has to pay. I finally received approval as a result of this external appeal in mid-Nov. So the appeals process is definitely slow and tedious. Highmark is betting/banking that you give up by this point. I spent an entire week on google, finding and reading research and medical journal articles to write my external appeal letter because I knew it was my last shot.

In my appeal letter, I focused on substantiating my position via the published medical data I found. I addressed their denial reasons point by point including; given my health status, why wls is “medically necessary”, due to personal medical and prescription concerns why the alternative wls (gastric bypass and lapband) weren’t appropriate surgical options for me, how the sleeve is proven effective and even safer for lower bmi patients, and finally the financial advantage for Highmark to approve the sleeve over the gastric bypass or lap band.

Everyone’s health status and medical issues are different, so your appeal letter will look very different than mine. The best advise I can offer in writing a compelling one is research for the medical data to refute the specific reasons why Highmark denied your claim and use that data to make citations in your appeal letter to support your position clearly. Highmark nor the (IRO) will care about the emotional reasons why you feel you need the sleeve. I am attaching a list of some of the journal articles I used in my appeal letter. I am sure there are medical articles more specific to your case out there. I would be happy to answer any questions I can. Let me know how it goes.

2.doc

Thank you so much! :biggrin:

Oh my!!! Thank you so much for taking so much time to reply. You hit the nail in the head with the reason I prefer the sleeve. I have degenerative disc disease in my neck and take ibuprofen/ anti- inflamatories daily... I don't think the bypass allows you to take these... I'm gonna keep praying... Sending in my request next month. I am thinking about sending all of the info I have researched ( including what you suggested) in my request. Think that is smart or not??

I am so excited for you... You give me hope... Wanna hear about the awesome things you are doing and how you are shrinking! Thanks again!!!

Hi, does any one know if Medicare will cover the sleeve? It covers the others I 'm disabled. And have high blood pressure,obese,diabetes 2. Anyone hear anything Barb

I was approved after being denied at first. If you want to take a look at all the information I included in my appeal you can check it out on my blog. Hope it helps!

This is a helpful post. Congrats on getting your sleeve finally!

This is how my appeals process went with Highmark BCBS. Hopefully some of this will help you prepare to appeal if needed. After being denied the 1^st time in August 2011 for the sleeve by Highmark because my bmi was below 50 and they considered my request for surgery not “medically necessary”' date=' I began my research to refute their medical policy concerning the VSG as the first surgery in a two-stage procedure for individuals they consider “severely-morbidly obese” +50bmi. What I found was that compared to current standard practices and commonly accepted opinion within the bariatric surgical community, their policy is really outdated. Thus the position statement update, by the ASMBA supporting VSG as a single stage primary procedure. I also had no difficulty finding medical article after medical article concluding the success of vsg for lower bmi patients.

In terms of an appeal I feel the fact that Highmark does cover the VSG, albeit only for high bmi patients, is still in your favor because you have a basis for arguing that the 50bmi is an arbitrary number based on current medical data. I proceeded through 2 internal appeals with Highmark which were of course denied before moving on to an external appeal. This involved an Independent Review Organization (IRO). Basically your case is sent out to a panel of impartial professionals who review everything from both sides to make a final determination. If they rule in your favor, Highmark has to pay. I finally received approval as a result of this external appeal in mid-Nov. So the appeals process is definitely slow and tedious. Highmark is betting/banking that you give up by this point. I spent an entire week on google, finding and reading research and medical journal articles to write my external appeal letter because I knew it was my last shot.

In my appeal letter, I focused on substantiating my position via the published medical data I found. I addressed their denial reasons point by point including; given my health status, why wls is “medically necessary”, due to personal medical and prescription concerns why the alternative wls (gastric bypass and lapband) weren’t appropriate surgical options for me, how the sleeve is proven effective and even safer for lower bmi patients, and finally the financial advantage for Highmark to approve the sleeve over the gastric bypass or lap band.

Everyone’s health status and medical issues are different, so your appeal letter will look very different than mine. The best advise I can offer in writing a compelling one is research for the medical data to refute the specific reasons why Highmark denied your claim and use that data to make citations in your appeal letter to support your position clearly. Highmark nor the (IRO) will care about the emotional reasons why you feel you need the sleeve. I am attaching a list of some of the journal articles I used in my appeal letter. I am sure there are medical articles more specific to your case out there. I would be happy to answer any questions I can. Let me know how it goes.

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Feel disappointment already...I have BS Keenan and a BMI of 42....I think it's hopeless for me hearing all these stories...I'm probably wasting my time & $

I had a medical savings account for 10 years and had enough in it for the procedure. Last year the cost of maintaining the msa went up 30% in one year, thank you Obamacare, so the accountant and the operations manager met with the other partners and I and we switched to bobs. Bcbs denied me but I needed that denial to cover my using the msa for the procedure. So if bcbs has a change of heart I would have to undo the MSA distribution( a Pain) or get audited. So I am one of the few people hoping my insurance denies me like they said they would. I add agin that msa accounts are great.