Appeal ready - want to give me feedback?

[brittu 42]

Hi all,

Well thanks to the great help from folks on the boards, I've got my appeal letter ready to ship off to BCBS. Anyone want to take a look? Offer me some advice? I've posted it here:

http://vsgappeal.blogspot.com/2009/06/introduction.html

...and would love to get your in feedback.

Thanks,

Britt

(forgive the multiple posts, not sure which areas get the most traffic)

Edited June 19, 2009 by brittu
update

[Keith 0]

I think your appeal is well written and appears well researched. I am interested in the source of your data for Fed BCBS coverage of VSG.

I am engaged in my own appeal although my situation is different. I went into surgery for a Roux -n-Y after my insurance (a self-insured plan administered by BCBS) denied the VSG as experimental/investigational. Well into the surgery (opened BOTH laproscopically and fully) the surgeon determined that the Gastric Bypass was not feasible due to my unique anatomy. He converted to a VSG after giving my wife that sole option simultaneously with the news that my liver was "foi gras" due to my obesity. Now, the insurance which pre-authorized the Gastric By-pass doesn't want to pay.

On the plus side, I have lost 100 pounds in five months and feel no hunger. I have been able to also get off the Metformin for my Type 2 Diabetes. All is not roses; no one would choose this if they had a real alternative to surgery.

[brittu 42]

Thanks Keith. I finally finished it off (and reposted the final version) today. It's now on it's way to the local BCBS. I actually expect that they will offer to remove the lap band but deny the revsion because I'm not >35BMI. Seriously, I think a lot of the insurance issues are related to weight discrimination. Pretty much any other diagnosis and and if the first treatment failed you'd have no problem getting a different treatment. Heck, if I had the symptoms I had without a lap band they would have been all over getting me in and covering whatever it takes to fix it.

For the Fed BCBS stuff I posted on a few boards asking for others who were covered and got several public and private responses. I also did lots of googling on the variants of VSG and Fed Blue to find people who had been covered and the name of their doc. Then googled or looked up on Obesity Help a lot of the docs that were mentioned. Then called around to see what the various doctor and BCBS offices said.

There were three states where the local BCBS administering for Fed Blue plan seems to have issues including Washington and California. In my state there are two BCBS offices that share administration of the plan and they disagree. The phone people are in the BCBS company that says it's covered but the pre-auth people are in the other company and say that it isn't. What's really frustrating is that there seems to be no Federal oversight of the plans that I could write or call to get this sorted out.

I didn't include the doctor's names in the post because I didn't want to cause them any trouble in case they were using one of the old CPT codes for VSG (before it had an official code). And generally didn't want issues to come up in the states where VSG has no problem.

If money wasn't a concern I'd probably already have gone to Dr. Aceves. But my hangup is what happens if I have a leak and need very costly emergency care. Who would pay for that. So if I can get some sort of coverage then I'll go with Dr. Cirangle in CA. There are a few local doctors here who do VSG but they just don't have the experience with revisions that Aceves, Cirangle and Hargroder have. I didn't really know as much about VSG and revisions when the pre-auth was submitted by the local doctor. It would be great if he could do it but they've only done about 100 VSGs and they want to do it in two surgeries six weeks apart. I just don't want that if it can all be done at once. And, heck, it's less than a used car if it comes down to self-pay for me. Well worth it. I loved my lap band while it worked.

I think you should continue to fight on appeal. How good were your surgeon's notes? Will their office write a letter saying they had no choice?

Much of the VSG info I used I got from Teresa who has a blog where she put her letter. I just added to it and wrote my own version. Also macmadame had posted a great list of studies and details that I referred to.

Congratulations on your weight loss and improved health! It's amazing to feel like you're in control isn't it? I wish things could have stayed that way for me. I want to kick myself for not trying to get control before I regained so much weight.

Britt

[Keith 0]

Brittu:

Don't be hard on yourself. If "control" was all it took, we would not need this surgery.

I have the operatory notes from the surgery. They were submitted to BCBS for the Level 1 appeal. From what they have told me they felt that they had no recourse under my plan but to deny my claim at the first level because VSG is not a covered service. They have indicated that they have more latitude at the second level and could at least cover some of the expense. Because mine turned into an open surgery I am dealing with much more than the cost of a used car.

My doctor did write a letter explaining that he went to "extreme" measures to perform the gastric bypass but that this was not possible due to my unique anatomy. Because I was open he stated that he "had to perform the surgery" and did the "best procedure he could perform" due to my situation. He is a Center of Excellence surgeon who has a solid background with the Roux-N-Y so he should know if it could not be performed.

He certainly did not appreciate the first decision which suggested that he could have done a lap band or a VBG. I was not a candidate for the lap band for several reasons. Apparently, the VBG is a "historic" operation and definitely not the standard of practice according to my surgeon. In fact, Medicare no longer covers it and I read that the AMA considers it an "extremely dangerous" operation.

Could you please point me to Theresa and, I think it is McMadam??, whom you mentioned in your response? I would like to read their VSG posts.

Best of luck and thank you! Keith

[brittu 42]

Well hang in there, my fingers are crossed for you. Someone replied on one of my threads that they finally had success with appeal 3 when they hired an attorney to help and won. They hired Walter and Kelley Lindstrom and it sounded like their written appeal was so effective it just turned the tide.

The blog posting I got good information from was from Teresa at ObesityHelp: The Diary of a Fat Woman: Deny Deny Deny!

Here's macmadame's great set of links: MacMadame's Profile

And then you can google phrases like "vsg insurance" "vertical sleeve insurance" and then "appeal" and the like. You can also google terms for VSG + the name of your insurerer and/or state and see what you get.

Best of luck! I'm pullin' for you.

Britt

[magsupply 0]

Britt - did your appeal get approved? Please let me know! You can email direct also magsupply@aol.com