Referral for Revision Denied...Need to Appeal

[dustycotton 0]

Hi - I'm new to this forum but needed to go somewhere to ask for some help. Maybe someone here has gone through this and can give some insights.

I had my original RNY bypass done 5/6/2000. I was 300# (5'6") and lost down to 155#. I remained there for about 6 years. Over the years I've had multiple ER visits for something "stuck" and epigastric pain with endoscopic dilation twice. In Nov 2012 I was hospitalized for the same issue but this time was told I might have Barrett's esophagus and was put on Protonix for acid reflux. I didn't know revision surgery even existed so when a friend told me about it, I went to a free seminar by the local bariatric surgeon group and was told with an RNY procedure I shouldn't be having acid reflux because the anatomy of the procedure specifically prevents it. They suggested I get back to my GI doc and get checked for Barrett's.

I went back to my PCP, who had referred me for the initial surgery, and discussed all this with him. He submitted a referral to a GI doctor and the bariatric surgeon. I was approved to the see the GI, but was denied the referral to the bariatric surgeon. I have since had a upper GI w/ lower bowel study done and an endoscopy with biopsy of potential Barrett's esophagus. Everything came back normal and I was told I have esophagitis due to acid reflux. Again, no idea why I have acid reflux to begin with.

The denial of the referral to the bariatric surgeons states, "We cannot approve this request because you do not meet your health plan requirements for this service. You must first complete a 6 month weight loss program through the Weight and Health Clinic prior to referral for weight loss surgery. As you have not completed this program, we cannot approve this request. Please contact your PCP for referral to the Weight and Health Clinic."

My plan benefits do not address revision WLS at all, only initial surgery. This is the exact wording in my plan benefits for initial WLS. I called my insurance and advised them that I already had WLS and this referral is being requested because I am having issues with my original surgery. I was not on my current health plan with my first surgery. At first she said they didn't know I already had surgery, then she said they did. Then she said their decision was based on the information they had which only stated that I wanted surgery to lose weight so they denied it until I've completed the program, per my plan benefits. She suggested that my PCP and I both appeal the denial with any additional information.

I contacted my PCP's office and they said they would wait until the results of the studies done by my GI doctor before they submit an appeal. Problem is, the results of those studies is normal, with the exception of GERD and esophagitis.

So now I'm faced with needing to write an appeal letter to my insurance company with all of medical records to try to get the referral approved.

I know this was long and if you're still reading, thank you. Does anyone have any suggestions for my appeal letter? Any help at all would be appreciated.

[jodie1961 77]

I am sorry I didn't see this earlier. My lap band removal was approved w/my revision to RNY bypass being denied. Long story, but the insurance clerk at doc's drug out the process...all I needed according to my insurance was peer to peer review (my treating doctor to insurance doctor) to discuss reason for needing the revision surgery. Anthem bc/bs told me if I were to appeal first, I would give up my option for the peer to peer review. I called my doc office and they scheduled a review time (by phone). I got my approval letter that week! didn't even do an appeal letter. (now my dr office wants both approvals to be put on one letter, so I am waiting again for that). But...maybe a peer to peer review will help the insurance company to understand you are not doing this for weight loss but the effects of the GERD from the original surgery. Good Luck.