Submitting for Appeal, again!

[warrior68 16]

Ok, so Today I will pick up another appeal letter from my PCP, that is supposed to be very strongly worded, My Surgeon, and his partner have both written appeal letters for me. I personally used a copy of Zenbunni's Appeal letter modified for my situation, and I wrote them a very personal letter explaining why I felt I needed the surgery. My surgeons office is handling the appeal for me, so I sent both the letters I wrote to them, and told them to use whichever one they liked best, they called back and said they were both outstanding letters, and they were going to submit both with the appeal. Today I will pick up my appeal letter from my PCP, and get it to my Surgeon, then Friday everything will be submitted to Excellus BCBS Blue point 2 under the expedited two day appeal process for hopeful approval. If nothing else, even if they deny me again they are going to have a lot of reading to do, 5 letters in total, and they will have to be more specific than, denied due to exploratory / Investigational.

I am trying so hard not to get to excited, like I do every time we submit for approval, but its gotta work this time, right? If It doesn't work I'll keep pushing until it does, but I sure would like to have this surgery sooner than later since I been screwing around with several denials all year long. I have to say when I first started this whole WLS process I thought it would go so much quicker than it has. I had all the dr visits done, clearance letters from the food shrink, nutritionist, support letter from PCP, and the needed weight loss done in just a couple weeks. It has been about a year of constant arguing, re submitting, arguing more, getting denied again, switching surgical procedures and re submitting, more denials. UGHH I'm thinking they have to give in at some point. Thinking back when I first met my surgeon we were looking at a June or July surgery, then denied, then we hoped for a Sept, Oct surgery, Now I'm watching December come and go very quickly.

[Eureka-C 20]

Thanks for letting us know. I can feel the pain and frustration in your post. I only had to go through one appeal over five months and it was pure torture. My heart goes out to you. Hang in there.

[weightnomore 8]

It must be soooo hard. Sorry you have to go through all that. But I personally feel that it is only a matter of time before all insurance companies will allow this surgery. They, if anyone, know of all the problems people have with the Lap-Band, they know that this surgery is less risky than Roux-n-Y, and patients have better outcomes. They are hooked on their 'long term data' excuse, but it really is no excuse because the surgery has been done for years.

My insurance did not cover it when I first looked into it, but changed in July 2010. My doctor believes this will be the gold standard wls in coming years. I hope you will get a huge surprise and they will approve you one way or another.

[Tiffykins 673]

Your diligence will pay off ! ! !

I can only imagine your frustration, but don't give in. Hopefully, you'll get approved and not have to deal with a peer review ! ! !

[PlannerGirl 3]

We're all here pulling for you. Please let us know the outcome.

I think it's outrageous for one BCBS to cover the procedure when another calls it investigational. There needs to be consistency. Also, to refer to at as exploratory, when there have been countless success stories is ridiculous. (Sorry, I really get on my high horse when insurance companies screw around with people's lives)

In any case.......best wishes for approval!

[warrior68 16]

Yesterday I spoke to the Nurse that handles all the appeals at the surgeons office, it seems as though everything is in line to be submitted today. The nurse, the surgeon, the surgeons partner, my pcp, and myself have all written letters for the appeal, My PCP wrote right in his letter than risks of not having the surgery, far out weigh any any possible risks associated with the surgery itself in my case. The Nurse at the surgeons office feels like there is almost no way they can deny me again, but having been there, heard that, seen that movie, read that book, I'm not gonna believe it this time until I get a approval letter in my hands. Everything will be submitted today, we are shooting for a expedited approval which only gives them 2 business days to review and decide, however if they dont accept it expedited they then have 30 days to review it and decide.

I'm hopeful that I will have some news regarding a decision by Tuesday evening, or Wednesday morning. For now I just sit, wait, wonder, and stress over it, lol.