Dreaded Denial Letter Arrived

[KabinKitty 11]

The letter came on Friday, Sept. 17th. It stated I had 10 days from the "date of the letter" to ask for a peer review. The letter was dated Sept. 9th. Today is the 10th day and it's a Sunday....SCREWED on that option.

I will contact the surgeon's office tomorrow about filing an appeal. Then (if I'm reading the letter correctly) when the appeal is denied, we can ask for a peer review.

Their reason for the denial (of course) was the ole experimental/investigational excuse.

My hospital was the first in the USA to perform the Biliopancreatic Diversion with Duodenal Switch. It is a malabsorbtive procedure in which a portion of the stomach actually is removed. In addition to the stomach becoming much smaller, much more of the small intestine is bypassed than with the RNY.

In 1978 Dr. Hess perfected and began performing this surgery. So, 32 years ago he began removing a large portion of his patient's stomach (a sleeve gastrectomy) and then doing the duodenal switch at that time or at a later date.

So, with a 32 year track record of success with the sleeve part of that surgery how can any ins. company call it investigational/experimental! BEATS ME!

[peatie 4]

I'm sorry you were denied and now have to go thru the additional stress.

What exactly is a peer review??

[ozzy22 0]

What insurance company do you have?

[KabinKitty 11]

I have Blue Cross/Blue Shield Blue Access PPO in Ohio. In some states BC/BS is approving the sleeve, but not in Ohio yet. I have had some other health issues that my surgeon believes would help the ins co consider the sleeve as my only option. So, the fight begins!! :001_tongue:

Of course there is the appeal, but the peer review is where my surgeon says he goes nose to nose with a doctor who would basically let my surgeon plead my case in person. It's rumored that my surgeon is real good at this.

Anyway, I expected the denial, but when you read it in black and white it's so REAL!

I've already begun composing a letter to BC/BS. It's basically a letter to introduce myself to them and explain what's gotten me to this point in my life and how I and my surgeon feel the sleeve is the only option for me.

[sleeveorbust 11]

im sorry to hear about your denial!!.. all i can say is keep thinking about yourself with the sleeve... and it will come to you!!!! All the best! <3

[KabinKitty 11]

I called the surgeon's office this morning and talked to the ins gal. Of course she is saying that this would be a long process, since BC/BS does not cover the sleeve. Duhhhhh I told her that at the seminar, but she insisted at that time she was getting BC/BS approvals for the sleeve with no problem.

I told her I have composed a letter to BC/BS for the appeal. She told me that the surgeon would be handling the appeal, be it a peer review or an appeal. She told me if I sent a letter that it would be considered the appeal.

I said that I would hope that the surgeon could use the letter along with what ever he was going to say. She told me that would not be a good idea, that the surgeon would handle it. I asked if I would get a chance to speak to him before the appeal or review...I didn't get the feeling that it would happen.

I don't have a good feeling about this now! :w00t:

[Linda91 0]

I also have BCBS of Ohio and need the Sleeve. I know that they are denying them based on "experimental". I also know that it is not experimental at this point but BCBS/Ohio chooses not to review this procedure again for updating. It is really sad for us that they will pay for the band and the roux-en-y surgery, but not the Sleeve!! I guess I will need to go ahead with the roux-en-y and if problems occur, BCBS/Ohio will have to pay all of the medical expenses including cost of future problems. I don't think the are looking at the future results of the different types o surgery. They are going to be the losers in the long run.

I wish you the very best!! I do hope you can win in the end. Please keep in touch with me via my actual email address of linda91@carolina.rr.com.

If we could afford it, we should get an attorney looking at this!!!

Linda Black

Sleeve needed

Roux-en-Y will probably be the way I have to go!!!!

[MINI-Me 196]

I called the surgeon's office this morning and talked to the ins gal. Of course she is saying that this would be a long process, since BC/BS does not cover the sleeve. Duhhhhh I told her that at the seminar, but she insisted at that time she was getting BC/BS approvals for the sleeve with no problem.

I told her I have composed a letter to BC/BS for the appeal. She told me that the surgeon would be handling the appeal, be it a peer review or an appeal. She told me if I sent a letter that it would be considered the appeal.

I said that I would hope that the surgeon could use the letter along with what ever he was going to say. She told me that would not be a good idea, that the surgeon would handle it. I asked if I would get a chance to speak to him before the appeal or review...I didn't get the feeling that it would happen.

I don't have a good feeling about this now! :crying:

I would call back and insist that you be granted an appointment with the surgeon or the insurance coordinator. If they are that confident of the appeal, they may be able to instill that confidence in you.

For other BC/BS patients out here - can you provide information on what state you are from & how you were approved? That may be good information for the surgeon to include in his appeal. While BC/BS are independent of each other - have similiar "franchise" coverage information in addition to medical support for the sleeve could be very beneficial in this appeal.

[KabinKitty 11]

Thanks to Fitatfifty I may have some more ammo to get my denial overturned. She got approved because of her diagnosis of Celiac Sprue.

So, I looked up the symptoms and I have ALOT of them. I'm in the process of getting my pcp to order a blood test. If that's not conclusive the next test is to be scoped and getting a biopsy of my small intestines. Heck they can biopsy anything they want if it gets me approved!

I talked to my surgeon's nurse (she's going to talk to him between surgeries today) and to my pcp's nurse (he's out of the office today) and should hear something later today or tomorrow.

I told both of them how important this is to get an approval...if I have it. Celiac Sprue is gluten intolerance and if you have it and continue to eat gluten it can permanently damage your small intestines. Good ammunition against an RNY surgery!

Oh, my surgeon's nurse asked if I was set on having the sleeve!? I said yes, I will NOT have gastric bypass!!! I think they have alot of people who have requested the sleeve switch to RNY just to get approved. NOT THIS CHICK!

[FitatFifty 11]

Thanks for the kudos. If you're positive for Celiac the other issue is that the R-N-Y is a malabsorptive procedure and Celiac patients don't need further malabsorption issues in thier small intesitines.

Hugs

Fit

[Kelkie 0]

Good luck KabinKitty! If there is anything I can do to help let me know. I live in Oregon, but have BCBS North Dakota, PPO. I got approved on appeal, due to a lot of issues with auto immune disorders and the medications that go with them. I also pointed out in my letter that the sleeve had been performed safely for decades for many conditions.

When I was originally denied, my surgeon's office wasn't going to do the appeal, they said I was on my own. The insurance coordinator typed up a letter from the surgeon stating his reasons for it being my only option, then added my letter to it. It was my letter that won the appeal. Good luck to all of you out there fighting your insurance companies. Don't give up. That's what they want.

[KabinKitty 11]

Kelkie,

I guess my surgeon is just the opposite in that I don't think he wants my imput. I don't know for sure, cause they are not communicating with me. I called and left a message with the nurse to let her know I had blood drawn for the Celiac test this morning (thanks to my pcp). I told her I'd let her know as soon as I get some results. She has not called me back.

I think that office is used to people giving up on being approved for the sleeve and they just get the RNY.

I think I'll call them again!!

[KabinKitty 11]

Hubby called my surgeon's office to cancell my Monday visit with the nutritionist, after she left me a message to say that I am doing good on my own and since my case is in appeal the appt isn't necessary.

Hubby also talked with the nurse, who said the surgeon has dictated a letter for the appeal and it's waiting to be typed. He told her that I would like my letter to be a part of the appeal if possible.

Then Friday (yesterday) afternoon I got a call from my pcp's office to say that my test for Celiac Sprue was negative. As soon as I had the blood draw I went back to eating gluten free and all my syptoms that were starting to show up again, began disappearing. My rashes are going away, my "gut" feels so much better and the gas and bloating is going away. I'm sure I have some intolerance to gluten, but maybe it's just not at the stage it shows up in a blood test yet...darn!

I will NOT settle for the RNY, no way, no how, NEVER!

I sure do appreciate all the support of you all. More than you will EVER know!! :thumbup1: