2nd chance

HI Everyone, I am really really struggling...I am seriously having the fight the insurance co & my PCP blues. Pasted below is draft copy of a letter that I am working on to send to the insurance co. and maybe even the insurance consumer division. Although a really tight squeeze for now, I am working on Plan B. Dr. Alvarez in Mexico, 9750 for sleeve. Here struggling...having gained 18 pounds since September 15--all of my clothes are fitting way way way toooooo tightly! Bumming Here's my letter! I just dont know what to do.... Any insight is greatly appreciated! I am not sure if I should be outright saying I want to request an appeal or just asking for an update. Please review and give me your insight. Thanks! Group/ID Number: XOH842901948/H06800 Primary Care Physician: Dr. Derek Kelly Diagnosis: 278.01 Morbid Obesity Procedure: 99241 Office Consultation Referred For: Office Consultation Requested: 12/9/08 Denied: 12/9/08 Services Requested: Consult with Dr. Vitello for a Sleeve Gastrectomy Referral Authorization No. 23,562—Denied (Referral Denied—This is a request for an out of network non-contracted provider with Managed Health Care Associates Managed Health Care Associates 2740 W. Foster Avenue, Suite 411 Chicago, Il 60625 FAX: 773-271-0264 Illinois Department of Insurance Consumer Division 100 W. Randolph Street Suite 15-100 Chicago, IL 60601 Greetings I a writing to formally request an updated status of the referral decision rendered in December 2008. First of all, the services requested are inaccurate. Since October 2007, Dr. Derek Kelly has provided referral authorizations for me to see Dr. Vitello regarding lapband adjustment. From October 2007 until September 2008, I visited Dr. Vitello for lapband adjustments and presented with complications of my adjustments on a monthly basis. Resultingly, September 2008, I had to have emergency surgery to remove my lapband due to slippage. I followed up with post-operative care with Dr. Vitello, who then consulted with me regarding revisional bariatric surgery. In the interim, I informed Maria, of Dr. Kelly’s office and contacted the BCBS of IL to be advised of my benefits coverage and protocol for seeking revisional surgery. At that time, I was advised of the criteria for coverage, which I meet now and did so at the time of request, and advised Maria of the same. She advised me to have Dr. Vitello submit the referral authorization and that she would handle the request, as she had handed the processing of all of my prior referral authorizations to Dr. Vitello. Upon mutual interest, Dr. Vitello petitioned for referral authorization for revisional bariatric surgery, vertical sleeve gastrectomy. My last follow up appointment with Dr. Vitello was October 31 and the referral authorization was submitted twice by Dr. Vitello’s staff (University of Illinois at Chicago) before warranting a response by the Managed Care Group. This petition submitted in full disclosure, my operative and post-operative reports and medical necessity substantiating the need for the procedure. According to my insurance terms, bariatric surgery is a covered benefit as long as it is deemed medically necessary; this is furthered for revisional bariatric surgery with indication that as long as the first bariatric surgery was medically necessary, there is no waiting period for clearance for the authorization of a revisional surgery. Additionally, according to my policy’s terms and conditions, I have been advised of the following: Repeat of a covered bariatric surgery may be eligible for coverage only when ALL of the following criteria are met: For the original procedure, patient met all of the screening criteria, including BMI requirements The patient has been compliant with a prescribed nutritional and exercise program following the original surgery Significant complications or technical failure (i.e., slippage, etc.) of the bariatric surgery has occurred that required take down or revision of the original procedure that could only be addressed surgically Patient is requesting reinstitution of an acceptable bariatric surgical modality. Dr. Vitello submitted his referral authorization to Dr. Derek Kelly indicating my request to reinstitute an acceptable bariatric surgical modality, vertical sleeve gastrectomy. On December 9, I received paperwork advising of a decision of denial for a consultation. It indicated the denial was based on the fact that the services are available in-network and the request was from a non-contracted provider. The basis of this claim request for out-of-network coverage is due to this surgical procedure being revisional bariatric surgery, which is an acceptable bariatric surgical modality. Secondly, the letter advised of an alternative for the non-approved service, to contact Dr. Kelly for a referral to an in-network specialist. On December 15, 2008, I met with Dr. Kelly in follow-up to the denial. Dr. Kelly advised that he needed to submit supplemental supportive documentation along with the referral for processing to secure an affirmative decision. Dr. Kelly then proceeded to review my operative report records from the surgery and reviewed my other health records in my medical file and interviewed me regarding my health status. Dr. Kelly indicated this procedure should take approximately 30 days maximum and to anticipate an affirmative response to proceed with revisional bariatric surgery and that I had his medical support in substantiating the medical need. I have been waiting since December 15, 2008 and to date am more frustrated now than ever. For the past 2.5 months, I have meticulously called Dr. Kelly’s office regarding a status update. Maria, the administrative assistant, has provided several updates. The updates have included the fact that the previous medical director retired and was replaced and the new director was then on vacation, to the medical director making request for additional paperwork (which was submitted), to the medical director needing to meet with Dr. Kelly regarding the details of the approval process for this type of referral authorization, to the medical director and Dr. Kelly being unable to meet to further discuss the nature of my referral, to Brenda communicating that there was never a properly submitted referral from Dr. Kelley to the Managed Care group which resulted in the initial denial decision. In my first direct contact with Brenda Blazek, the Referral Coordinator who signed the referral denial letter, she claimed to know nothing regarding my case and further indicated that there was no documentation in my file. When I followed up with Maria with Dr. Kelley’s office, she advised that Brenda did not find any information in my file because all of the information was being held by the medical director. Whatever the real case is, this is neither professional nor acceptable in accordance to my patient’s rights under section 502(a) of ERISA. Just yesterday, I called and spoke with Maria five times to get an updated status, to exhaustedly be declined, yet promised an update by the end of the work day. I have not spoken with Maria, nor have I missed an update call from Maria. This has been my experience for the last 2.5 months. Below is an excerpt of the fax sent to Dr. Kelly, which was confirmed as received by Maria on February 5, 2009. Maria, I would like to reiterate that on 12/9 the referral authorization stated that the procedure, Vertical Sleeve Gastrectomy, is a covered benefit in-network; however my request was to have the procedure done by an out of network provider. Additionally, this was confirmed by Tammy on yesterday at 12:50 with Blue Cross Blue Shield that this is a covered medical benefit as long as it is deemed medically necessary. My appointment with Dr. Kelly in December was to have provided me with a specialist referral to have the procedure done or we could have executed an appeal. I think Dr. Kelly submitted an appeal for coverage of the procedure; however, I am requesting to have this surgical procedure done by Dr. Vitello or be advised of the in-network provider who can perform this surgical procedure. Even in accordance to the appeals process, the timeline has been elongated to address issue of medically necessity when that is not the matter—the issue is approval for out-of network coverage or referral to an in-network specialist. I hope this clarifies the situation more. I will call you tomorrow to see if you have an updated response. Additionally, I was contacted by the non-contracted provider’s office as a follow-up to the request in January and February. Last week, I advised them of the insurance referral hassle that I have been experiencing and they formally resubmitted their request, directly to Dr. Kelly (attention Maria), to the medical director of the Managed Care Group and to Brenda Blazek. To date, no response has been received; however, they have confirmed receipt of such documentation. Resultingly, I am assuming that since the only official documentation I have received to date is the referral denial, then I am evoking my patient right to request an appeal, specifically an expedited appeal process. However, I am highly dismayed because Dr. Kelly advised that there would be no need to execute an appeal. I would like to seek clarity first on the status and if this is in order, I would like to request an activation of the appeals process and under separate cover I will or will have my attorney to handle the appeals process. Before escalating to that level, I am very much interest in seeking resolve immediately. If and when I need to activate an appeal, I am requesting an expedited appeal process because my health at this point is continually declining and it is therefore imminent and serves my best interest to not further jeopardize my quality of life by waiting for a decision. Since December, the following symptoms I have presented: my breathing has become labored and therefore results in extreme shortness of breath my severe obstructive sleep apnea condition has worsened (hypopnea with severe oxygen desaturation) my acid reflux has returned my amenorrhea has returned and I have again began experiencing tumultuous joint, knee and lower back pains

Ok, so you all have heard my sorry...lapband removal! Well, I just got the final hospital bill....initially it what $19K, it has now increased to $38K! :eek:This is ridiculous....but thank GOD for insurance, as I am only responsible for $250 copay. Now, I just continue to pray that this great insurance coverage continues and covers my revisional wls to vertical sleeve gastrectomy. Best regards! What's been your experience with the staggering hospital bills/charges?

Insured through work--Blue Cross Blue Shield of IL I read your journey...wow! Best Regards Whats your current status...are you seeking revisional wls? Considering another band? Sheena

Hi Ladies & Gents, I have an update for you. Today, I visited my doctor and received a good recovery report ( I had to have emergency surgery to have my lap band removed due to slippage & a 20 month ordeal of unsucessful fills & unfills--I could never go longer than 3 wks without having to get an unfill--it would have been 2 yrs in December since lap band implant). Additionally, we began the process to submit for approval for a revisional wls to my insurance company. Wish me well! I decided upon vertical sleeve gastrectomy. We discussed all of my questions about his protocol with the procedure & I am convicted in this decision as being the next best option for me. He stated that we should anticipate about 1 month for the approval process and that I should begin to decide if I would like to have the wls before or after the holidays. I immediately announced before the holidays...I need to finish this weight loss journey ASAP and I cant have it to negatively impact my dissertation timeline. With the lapband, I lost 33 pounds prior to fill 1 and then lost 14 pounds thereafter. I love those results, but still aspire to drop another 30/40 pounds. I have to say I am a lil bit nervous in considering this new wls attempt...why? Because in this time that I have been in recovery, I only eat as much as I could with the band. I have not exercised, but for the most part have maintained my weight. I am afraid that what if the problem is not Portion Control and something else. I am not an emotional eater; however, my friends say that I unknowingly starve myself to death.:tt1:..to me I just dont really have an appetite or think about eating some days...yes, bad! I know. Any insight or words of wisdom?:smile2:

This is my abbreviated story: Update: September 17, 2008 9pm My lapband was cremated ..I had the inevitable deal breaking experience of my failed relationship between my body and my lapband. After 20 months of fills and unfills, which led to stoma obstruction & finally pouch dilation & band slippage...I was forced to make a quick life-changing decision. I had to give up my band due to slippage and the reality that I could not say that the band was the best fit for me and lifestyle stresses. I do think and feel that my lifestyle and how I internalized stress definitely compromised the ultimate maximization of the efficacy of the lapband. However, I continue to perservere through this journey of weight management as a life long struggle. Before Banding: 247 lb highest weight Average Weight Post Banding: 210 lbs. At Cremation of Band: 201 lbs.

My insurance will cover wls/revisional as long as it is medically necessary. So I am really eager to see the letter developed by my wls surgeon to be sent to my PCP for approval. I did not/do not have any esophageal problems resultant of the band. During the experience, I would have esophageal spasms, not much vomitting, dehydration. My band slipped and because of my progessive pattern of non-productivity/efficiency on the behalf of the band & its ultimate impact on my quality of life--I requested band removal! Prayerfully, I can proceed toward the next step...vertical sleeve gastrectomy.

Hi Ladies, I have an update for you. Today, I visited my doctor and received a good recovery report. Additionally, we began the process to submit for approval for a revisional wls to my insurance company. Wish me well! I decided upon vertical sleeve gastrectomy. We discussed all of my questions about his protocol with the procedure & I am convicted in this decision as being the next best option for me. He stated that we should anticipate about 1 month for the approval process and that I should begin to decide if I would like to have the wls before or after the holidays. I immediately announced before the holidays...I need to finish this weight loss journey ASAP and I cant have it to negatively impact my dissertation timeline. I have to say I am a lil bit nervous...why? Because in this time that I have been in recovery, I only eat as much as I could with the band. I have not exercised, but for the most part have maintained my weight. I am afraid that what if the problem is not portion control and something else. I am not an emotional eater; however, my friends say that I unknowingly starve myself to death.:tt1:..to me I just dont really have an appetite or think about eating some days...yes, bad! I know. Any insight or words of wisdom?:smile2:

Re: scars. My scars were dark. My new scars from band removal look better than my initial scars. I initially thought that the thickness of 2 of my scars were keloid; however, when I consulted with my doctor, he was adamant that it was not keloided. He stated that it was an adhesion. This is a natural occurrence of how the body begins to heal itself. It is a thick internal scar tissue formed at the incision site. Through this band removal process, my mother had me using a heating pad following my an ice pack :eek:and Mederma on my new incisions. I can tell you that I see a world of difference :thumbup:between the new and old scars and the feel of the old scars. Specifically, the old scar (port placement scar) was the thickest, even after the removal, it is not as thick anymore, just darkest. The new scars are no longer thick, nor are any of them dark. :pray2: If I so choose, I should be able to easily wear a 2 piece and not look bullet ridden!:grouphug: Best regards! Hope this information can help, as it is a relevant woman of color issue!

Yes...its all tax deductible...every expense...including gym membership. I am speaking from experience b/c I certainly reaped the benefits from it in Jan 07 tax refund.

To the original post.... Congrats on your weight loss...continue to work it! I was having the same problem with my photo. Got into your control panel of your profile and go to change avatar and upload your pic there...it will then display. You probably posted as I did where they indicate to post your photo; this is not linked to your avatar--which displays when you post. Best wishes. Sheena

I am convinced that its part of the dysfunction of the health care system. For fills, if you self-pay can be as cheap as $150 (non-fluro); however, let insurance cover it and they are billed nearly $2K. What a rip off...but thats they system so let it work. I just got my bills from my emergency surgery to remove my band....$20K---thats another surgery. However, I am grateful that all I am responsible for is $250. Insurance works so work it!

Good morning, Similar to slim n thin, my 6 month dr supervised diet was 6 months of office visits of weigh ins; however the dr wrote a very detailed letter--this is part of your medical necessity letter--which profiled each month, with exercise, diet modifications, rx. The purpose is to attest that no matter what the regular norm of weight loss initiatives are not working and thus the impetus for wls. When I began the process, my dr got preauthorization in November; however by Jan. by employer opted to exclude wls from its insurance coverage. So I ended up being self-pay. I would say whatever you can do to ensure coverage--jump through the hoops! Perhaps if you start now with your dr office they can begin, maybe you've been to the dr the last 3 months and they can reference those weigh ins? This certainly borders on professional ethics and you would not want anyone to compromise their integrity. WHAT'S FOR YOU..IS FOR YOU!

Hello, You are doing great! I lost 33 of my 46 pounds prior to fill 1. The liquid diet works so work it! :thumbup:Get used to passing INGESTED AIR in a whole new way...Although my band has been removed, I still burp alot, I was never a burper, before the band....and I still get my IM FULL HICKUP. Enjoy the ride! It shall be great!:thumbup: Sheena P.S. Thanks for your well wishes! I am doing well and am planning to return to work on Monday and am set to begin the new process on 10.31.

Best Wishes Sheena!!!! Now you said you had the band removed? What happened? And what form of wls are you planning on next month? Goodmorning, The last 20 months offered me nothing but fill/unfill:drool:...I could never go more than 3 weeks with a fill..which for a while would feel great and one day I would just wake up it no that it was yet again time for an unfill....sometimes this was a trip to the ER in the middle of church, sometimes I could hold out a day or two, sometimes it was an emergency call to the doctor to fit me in to do an unfill...It was progressive gradually. Below is a summation of my lapband experience from implant to removal, I have indicated the symptomatic issues that were experienced which led to the unfills. I did not indicate that the first 2 unfills were resultant of having been too tight and having flown. Lots of doctors and other bandsters will tell you that this is impossible, but I found research that speaks to a few bandsters being impacted by flying if they are already too tight--that indeed was my experience. :thumbup: Although I had these issues, during the process, I did not see them as complications--I loved my band. :tt1: I would advise everyone to be your own medical health advocate, challenge the opinions, research--become your best expert on yourself and this life transforming process, document your process...it was my only comfort in tracking my progress and ultimately seeing the regressive pattern. Dont just leave it up to the doctor to know and track everything with your progress/process. Everytime I got an unfill, I was asking is this normal, should I be concerned. By year 2, I figured that I was going to regulate the amount of fills that I was getting b/c what I had learned from year 1 was that the doctors had been too aggressive in my fills administration. From that I saw progress, but each time it was short lived..it did not make sense (levels that I had been at before were now too tight). Pay attention to your body, monitor your progress. At my last unfill, I was adamant in being concerned about the steady pace of fills/unfills/deflates...so much so that my doctor had to admit it too...and then we began discussing the option of getting an endoscopy done in 1 month....needless to say we didnt have that time...as 2 days later I had been admitted to the hospital and the emergency call had been made to remove my band. :regular_smile: At those fill appts., insist on knowing how much of a fill is being administered and knowing what your total balance is. Document this every visit. It cant hurt..it can help in the accountability process in the long run. During those periods of unfills being needed, I would lose 5-8 pounds over night.:tt2: Even if I could do this all over again, I know that lapband would have been my first choice & vertical sleeve my second. At the time of my decision I had not heard about vertical sleeve. I am hoping to have the vertical sleeve gastrectomy next month. And if that dont work I will go back for the second stage of the sleeve; however, I doubt if I will need it. I lost 46 pounds with the band & hope to lose another 30 pounds. I am hopeful!:w00t: November 16, 2006--surgery performed; weight: 247 December 2006--weight: 225 January 3, 2007--weight: 211; first fill administered--1cc in 4 cc band February 2007--weight: 215 March 2, 2007--weight 207; 2nd fill administered--1cc added--total 2cc in 4cc band April 23, 2007--weight: 204; 3rd fill administered--1.1cc added--total 3.1cc in 4cc band May 23, 2007--weight: 198; 1st unfill administered--2.3cc removed---total 0.8cc in 4cc band (acid reflux, esophageal spasm, stoma occlusion) June 26, 2007--weight: 209; 4th fill administered--1.2cc added--total 2.0cc in 4cc band July 10, 2007--weight: 212; 5th fill administered--0.8cc added--total 2.8cc in 4cc band August 2007--weight: 212 September 2007--weight: 212 October 4, 2007--weight 212--2nd unfill administered--0.5cc removed--total 2.3cc in 4cc band October 30, 2007--weight 212--6th fill administered--1cc added--total 3.3cc in 4cc band November 6, 2007--weight: 206--3rd unfill administered--0.5cc removed--total 2.5cc in 4cc band (acid reflux, esophageal spasm, stoma occlusion) December 2007--weight 215 Year 1: 6 fills; 3 unfills; weight fluctuation range: 247-198 weight loss: 49 pounds; weight gain: 30 pounds ************************************************************************************************************************************ January 22, 2008--weight: 217; 1st fill administered--0.8cc added--total 3.2cc in 4cc band February 12, 2008--weight: 213; 1st unfill administered--0.5cc removed--total 2.7cc in 4cc band March 2008--weight: 217 April 29, 2008--weight: 216; 2nd fill administered--1cc added--total 3cc in 4cc band May 6, 2008--weight: 207; 2nd unfill administered--.02cc removed--total 2.8cc band May 18, 2008--weight: 204; 1st deflate--(acid reflux, esophageal spasm, stoma occlusion, dehydration) May 27, 2008--weight: 204; 3rd fill administered--2.5cc added--2.5cc in 4cc band June 26, 2008-weight: 204; 3rd unfill administered-.8cc removed--total 1.7cc in 4cc band July 2008--weight: 204 August 19, 2008--weight: 209; 4th fill administered--.5cc added--total 2.2cc in 4cc band September 15, 2008--weight: 201; 2nd deflate--(pouch dilation, esophageal spasms, dehydration) September 17, 2088--weight 201; lap band removal Year 2: 4 fills; 3 unfills; 2 deflates; 1 band removal weight fluctuation range: 217-201 Max. weight loss: 16 pounds; Max. weight gain: 9pounds

Hi, I am a newbie to this site and just lost my band and am convinced that the vertical sleeve is my next best option. I am writing to inquire of the "sleeved" about their experiences with pbing, sliming or food getting stuck? Is this real? If so, is it similar to the band experience? How long does it take to pass? What are suggestive tips to get the food to move along since "being too tight" and getting an unfill isnt an option? Please advise. Thanks! Sheena

Greetings, I am a newbie to the board & am in the process of recovery:girl_hug: from my lapbad removal:thumbdown: on 9.17. Year 1: 6 fills; 3 unfills; weight fluctuation range: 247-198 weight loss: 49 pounds; weight gain: 30 pounds Year 2: 4 fills; 3 unfills; 2 deflates; 1 band removal weight fluctuation range: 217-201 Max. weight loss: 16 pounds; Max. weight gain: 9pounds I have followed up with my insurance to ensure coverage--confirmed--and I have followed up with my PCP to ensure protocol--letter from referral doctor of medical necessity. I have followed up with my referral doctor/wls surgeon to advise that my PCP needs a letter of medical necessity to submit for approval for authorization. I am schedule for my one month post op follow up visit with my wls surgeon on 10.31. I have confirmed the co-pay for wls in-patient is $250/outpatient is $150. :laugh: I was selfpay $8500 plus travel for my lapband--Dr. Ortiz--Obesity Control Center in Tijuana, Mexico in November 2006. So the opportunity to get this wls covered by insurance is FANTASTIC! I can say that my insurance/PCP have been great b/c they covered all but 2 of my fills--and that was before I realized that I could petition for coverage. :huh2: I am hopeful/prayerful that there are not too many hoops to jump through and that the best case scenario renders that I can anticipate my wls to occur near the end of Thanksgiving--yes this year--like in a bit more than 30 days! I am wrapping up my last semester of coursework on my doctorate degree in higher education leadership and am working on chapters 1-3 for proposal defense & have comp exams coming up in 3 weeks...atop of returning to work on Monday.....so I already have a lot of hoop action already going on!:tt2: Wish me well!:cool2: Sheena

Hi Ladies, My name is Sheena. I live in the metro Chicagoland area. I was lapbanded in Nov 2006. I was a self-pay patient and went to Mexico to Dr. Ortiz. Wonderful experience--first hospital/surgical experience. For the past 20 months, I had been plagued with fills and unfills...stress induced stoma occlusions, then most recently pouch dilation that led to band slippage..This resulted in being horribly sick for 4 days...no water/food tolerance/dehydration...immediate emergency surgery for band removal. Immediately, I began researching new weight loss surgery options and have concluded that my best option seems to be the vertical sleeve gastrectomy. I am single, no children, very supportive boyfriend and mother. I serve as a college administrator, and am a member of Delta Sigma Theta...OO-OOP! I shared the decision with most folks in my life regarding lapbanding; however, because everyone felt like I should have given up the band far soon than I did, I have decided to not share this decision...they'd think I am really crazy... My doctor has confirmed coverage by my insurance and his skill in performing the procedure. Of course, I have a page full of questions; however, I am certain that his immediate response again will be let's wrap up your recovery and then plan the next step. I am already there... As I work in college administration, I am hopeful to fast track this process. I believe that the most forgiving time for wls is between November Thanksgiving break and the return of the new semester in January. Therefore, I am most interested in having my wls during this time period. We will see. Best regards to all!

NFaith, Hey There I was banded and went to Day One Health--900 N. Michigan Avenue (Water tower Place)-- and self paid for fills before I got insurance approval for coverage. You pay $250 under fluoroscopy or $100 blind. Best regards.

I had the band for 22 months, up until 9.17 and was able to wear Spanx. No problem. I personally preferred body briefers, but this is a personal preference. I found that after lapband surgery, my underwire bras sometimes were uncomfortable. Best regards

Hi, I was a selfpay patient for lapband surgery in Mexico. At that time I lived in Atlanta, Ga and was caught in the midst of an insurance company writing in an exclusion. Shortly after my surgery, I accepted a job offer which relocated me to the Chicagoland area. Resultingly, my insurance, BCBS HMO, paid for my aftercare fills. I got my fills at UIC by Dr. Vitello...wonderful doctor...he was actually recommended by my original surgeon. I had to have my band removed via emergency surgery on 9.17 and am certainly committed to continuing the battle against weight managment. I would recommend Dr. Vitello at UIC. Best regards Sheena

Kia, I certainly feel your pain. I too lost my band..on 9.17. I had been struggling for the last 20 months with getting fills then unfills. I am recovering now and am convinced that I will press on to another wls option. To that end, I have comprehensively researched the typical next option for failed bandsters...vertical sleeve. It seems like such a great next choice. I wish you well in your continued journey. In my journey, at my heaviest, I weighed 247 and prior to my first fill I had lost 33 pounds; then over the course of the next 20 months-went back and forth with 10-15 pound weight loss. I hope to lose 40 more pounds, so I understand your logic in not wanting to go the most aggressive route for this amount of weight loss. Press on sister, & PUSH through this journey! Best regards Sheena