Revision Denial- HELP PLEASE

[Heath55 17]

On 01/02/13 I had the sleeve done and unfortunately it just didn't really take. Of the 365lbs I started at, my lowest weight was still in the 290's post op. Last June my mother died unexpectedly and young just like her father and brother (all cardiac traumas and it runs significantly on my fathers side too). It scared me into getting myself together and getting back on track, which I've been doing. While I lost only a fraction of weight the first time my quality of life and activities was and has been phenomenal but unfortunately I'm still borderline diabetic, I'm putting stress on my heart, my PCOS is out of wack with multiple cancer biopsies due to this, I started to have high blood pressure and the extra weight caused foot problems. I had two surgeries on my R foot in the last 6mons with little success and he feels my weight is a considerable part of this. I'm doing PT 3x's a week to regain mobility but that's significantly slowed me down.

I work in the healthcare field and know the system pretty decently but today AmeriHealth denied my revision for full bypass. For my first surgery I had Horizon and AmeriHealth told me that as long as it wasn't through them because they're a "one and done" provider and I meet the medical criteria that wouldn't be an issue. I'm currently about 300-307 and my BMI is about 49 and I'm being denied. I'll attach the criteria they sent me again today but any tips on making this happen would be immensely appreciated. Quite frankly I'll die before 60 like my mother with all of my medical issues that could be alleviated and even eradicated with proper weight loss. I'm going to try and attach a screenshot that I was given by my insurance subsidiary in NJ and if someone can tell me how I don't qualify please go for it because I can't fight something I may be too close to see. I'm feeling really frustrated and defeated but I refuse to roll over. After some pushes with calls today I will have a peer review but they don't know when. Thanks for making it through my ramble.

 

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[FDclerical 318]

Keep fighting. Your bmi alone should have you approved revision or not! Maybe escalate it to the medical director of the insurance company and hopefully they reconsider. Also try getting more than one letter of medical necessity like from your pcp and surgeon but I've read the peer reviews always succeed. Good luck to you !!!!

foreverbariatric

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[Heath55 17]

That's my thoughts and I didn't even come clt she to meeting their 50% loss for the revision criteria. I asked my surgeon for my feet to write a letter of medical necessity from his end so hopefully that'll kick it up. The letter from my PCP was very detailed and supportive so I really don't understand how I got denied based on her recommendation as well. I literally was up all night panicking and went to bed about 11am after talking to a few specialist offices and my Bariatric coordinator. Pathetically I cried for most of the 15min call but she said the review is scheduled for Wednesday. I saw a lot of people say that did it for them so I'm trying to remain hopeful. Thanks for chiming in and the support, I feel like I'm going crazy over here.

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[rachelmorrow 0]

I'm in the begining stage of the revision process with United Healthcare. Please keep me posted on your story. I'll be praying for you!!! I know how frustrating it can be, believe me!

[Heath55 17]

I'm just heard from my surgeons office and the doctor "surprise" called a day early as she called it and "upheld the denial" so now I need to do a personal appeal called a Level II appeal and I'm going to request a TTY third-party review of the chart.

The doctor that reviewed it is a known strict ass and he denied it saying that just because it didn't work the first time doesn't mean I should get a second one. They said that the second they heard his name they knew the answer. I got quiet with her on the phone so after a pause she continued on even though I was silent and as I had to briefly speak and she knew I was crying she said "and that is what you need to show them when you make your appeal". I already had to collect myself and hide my crying before I went back in with one of my patients and I literally want to throw up I'm so upset and afraid.

Good luck with yours, it seems like is more about my provider and that specific doctor. Let me know how yours turns out, I'll curious about other providers mentalities.

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[clc9 644]

Maybe in the meantime while you wait you could read up on the advice from the vets here for starting over after regain? Getting the very most out of your sleeve while you have it might give you some feeling of control in an out of control time.

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[Heath55 17]

I have looked but sometimes maneuvering the vast threads is daunting. On my drive home I'm gonna call my insurance company and start the process. Doing the surgery over again was scary enough and now with a crushed view I feel defeated.

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[clc9 644]

In the last few days, @@Babbs has had some good lists of things to do to get started again. Maybe searching through her recent posts would be less overwhelming? I can imagine you feel defeated, but know you aren't powerless. If you can't have revision surgery, you can still work your sleeve as best you can. Best case scenario, you're just that much healthier for surgery. Good luck!

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Edited January 10, 2017 by clc9

[Heath55 17]

Rachel I won my appeal finally! I fought and fought and after the peer failed I began the personal appeal and nailed it. I found out on Thursday, saw my doc on Friday, went to the pre-op class today and surgery is Tuesday the 7th. What a whirlwind. I hope yours is going smoother than mine was.


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[hmills653 365]

My nutritionist said every do often there are people that get denied. Keep going through your classes or anything you are doing but ask your physician office to appeal it. They have a certain amount of time to file an appeal.

[120Cassy 5]

On 1/5/2017 at 3:44 AM, Heath55 said:

On 01/02/13 I had the sleeve done and unfortunately it just didn't really take. Of the 365lbs I started at, my lowest weight was still in the 290's post op. Last June my mother died unexpectedly and young just like her father and brother (all cardiac traumas and it runs significantly on my fathers side too). It scared me into getting myself together and getting back on track, which I've been doing. While I lost only a fraction of weight the first time my quality of life and activities was and has been phenomenal but unfortunately I'm still borderline diabetic, I'm putting stress on my heart, my PCOS is out of wack with multiple cancer biopsies due to this, I started to have high blood pressure and the extra weight caused foot problems. I had two surgeries on my R foot in the last 6mons with little success and he feels my weight is a considerable part of this. I'm doing PT 3x's a week to regain mobility but that's significantly slowed me down.

I work in the healthcare field and know the system pretty decently but today AmeriHealth denied my revision for full bypass. For my first surgery I had Horizon and AmeriHealth told me that as long as it wasn't through them because they're a "one and done" provider and I meet the medical criteria that wouldn't be an issue. I'm currently about 300-307 and my BMI is about 49 and I'm being denied. I'll attach the criteria they sent me again today but any tips on making this happen would be immensely appreciated. Quite frankly I'll die before 60 like my mother with all of my medical issues that could be alleviated and even eradicated with proper weight loss. I'm going to try and attach a screenshot that I was given by my insurance subsidiary in NJ and if someone can tell me how I don't qualify please go for it because I can't fight something I may be too close to see. I'm feeling really frustrated and defeated but I refuse to roll over. After some pushes with calls today I will have a peer review but they don't know when. Thanks for making it through my ramble.

 

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I thought that weight loss surgery revisions are given due to problems with the first surgery, such as severe gerd (which sleeve patients tend to get and that's why they get it revised), slippage (gastric band) and or throat stricture issues (or something like that)? A few insurance companies believe when a procedure doesn't take it's due to the patient and not the procedure itself. That's why when we choose the surgery the first time, your primary physician usually guides you on what they think may be best based on your weight issues (at least that's what my doctor is doing). I hope you get approved. Don't give up. I'm not sure how many times you can appeal...but I'd appeal this as much as I can. Possibly get your doctor to do tests for Gerd issues or issues with the sleeve itself and not the weight issues and health. Those reasons were the reason you got the first surgery. Maybe going about it a different way may help. I know this is coming months after you posted, but I thought I'd reply just in case. :-)

[Heath55 17]

Thanks! It was approved after I quoted their own policy and I had the surgery 03/07.

[Chastiny caldwell 0]

On 2/28/2017 at 4:14 AM, Heath55 said:

Rachel I won my appeal finally! I fought and fought and after the peer failed I began the personal appeal and nailed it. I found out on Thursday, saw my doc on Friday, went to the pre-op class today and surgery is Tuesday the 7th. What a whirlwind. I hope yours is going smoother than mine was.


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Hello, my name is Chastiny and I've reviewed your time-line. Our situation is the exact same, however my scheduler is always to busy to stop and write the appeal. I'm actually afraid she will submit appeal without support. Peer to peer was 2 weeks ago and denied. What should be my next step?

[SpartanMaker 1,350]

sorry, just realizing this was an old post.

Edited September 13, 2022 by SpartanMaker