Post by Deleted on Feb 19, 2012 15:36:16 GMT -5
The following is a PM conversation I had with Diana Cox today -- THANK YOU DIANA! I'm posting here (at Diana's request) in hopes that that may likewise help others.
First is the PM I sent Diana today (thanks to Larra for suggesting I contact her directly) followed by her response. I'll keep documenting the process so that we may all benefit.
~Liria
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Diana,
I'm trying to find info on rny to ds revision denials for those of us who have not been inside the medical system for years (so really not much in the way of documentation). Following is a brief outline of my situation. Not sure whether you need the rest of this info, but in case it puts me clearly into one basket v another, here it is.
With a BMI of 50.7 and multiple co-morbs, on Friday, 2/17 I was denied pre-auth for RNY to DS revision with Dr. Keshishian in CA.
My insurance is CA PCIP which is now through First Health Network. The only statement in my policy about WLS is that it's covered if medically necessary. Of course the reason given for denial was *not medically necessary*. What I was read by the insco said we hadn't proved mechanical failure v. patient failure of the RNY. In your experience, is that kind of denial often overcome without lots of detailed past medical records?
I'm trying to assess the likelihood of a successful appeal given that prior to PCIP (effective date 12/1/11) I hadn't had health insurance in years so I don't have well documented medical history or doc appts within the past several years to document weight history or physician supervised dieting.
In your experience, without that kind of documentation (or much in the way of diet/gym receipts I keep reading about), do inscos reconsider?
The one thing I hope I can document is that I had severe anemia in 2003 (2.5 years after RNY), had a hysterectomy that did not correct it, had all kinds of oral iron and infusions that didn't correct it and was told that I had to eat a lot more red meat and other iron rich foods, which ultimately did correct it.
My BMI is now 50.7 I went for a physical in January, learned I have high BP, raging Diabetes despite a low carb lifestyle. So far the meds aren't working. Dr. K is pretty clear that the meds will do nothing but cause me to gain another 50lbs. NOT acceptable! My first priority is to regain my health.
I want to be on the other side of this revision soon and I CAN do it without insurance. It'll clean me out financially for now, but if that's the definitive and expedient answer, then so be it.
Your thoughts and any resources you are familiar with that might help me make this decision and/or appeal the insco's first denial would be sooo welcome.
Thanks so much for taking the time to read.
I hope I can return the favor in some way!
Liria
-----------------
I couldn't find your post - I'd appreciate it if you could repost my answer there, so others can benefit from it.
First of all, IF your insurance plan is regulated by the CA Dept. of Managed Health Care, this should not be an issue. But I don't know whether it is, since I'm guessing PCIP is the mandated health coverage program. PLEASE find out what your right of appeal is, ASAP.
Second, I think you can make a compelling story about not having had health care to prove what your medical condition has been in previous years. Just write it up.
As for documenting mechanical failure vs. patient failure, that is Dr. K's job. He needs to explain why your surgery needs to be fixed. He's pretty good at that. BUT PLEASE - ask him NOT to send anything in to your insurance company without letting you review his draft (we saw a recent letter of his which was apparently NOT reviewed by him after dictation and it was HORRIBLE with typos, errors, incomplete and illogical sentences) AND without you sending it to me and Lorraine (Larra) - we work as a team to help people get insurance coverage for the DS. In the meantime, please send me an email that includes this PM thread, along with explicit permission to include Lorraine in the conversation - PM is an impossible way to communicate. dianahc@comcast.net
Your documentation of having been given instructions to eat a certain way to address your anemia, which instruction may have been in conflict with how to maintain your RNY results, should be very helpful - they cannot say you were not compliant, if you were instructed to do this and did. And then we can argue that this is yet another compelling reason for revision to DS, because the diet you need to prevent anemia is the same diet that is recommended for DSers.
I believe you qualify AS IS for the DS - but your insurance company is simply trying to discourage you. We might be able to get them to retract the denial after one appeal, but be prepared to have to go all the way to external review.
-------------------
First is the PM I sent Diana today (thanks to Larra for suggesting I contact her directly) followed by her response. I'll keep documenting the process so that we may all benefit.
~Liria
---------
Diana,
I'm trying to find info on rny to ds revision denials for those of us who have not been inside the medical system for years (so really not much in the way of documentation). Following is a brief outline of my situation. Not sure whether you need the rest of this info, but in case it puts me clearly into one basket v another, here it is.
With a BMI of 50.7 and multiple co-morbs, on Friday, 2/17 I was denied pre-auth for RNY to DS revision with Dr. Keshishian in CA.
My insurance is CA PCIP which is now through First Health Network. The only statement in my policy about WLS is that it's covered if medically necessary. Of course the reason given for denial was *not medically necessary*. What I was read by the insco said we hadn't proved mechanical failure v. patient failure of the RNY. In your experience, is that kind of denial often overcome without lots of detailed past medical records?
I'm trying to assess the likelihood of a successful appeal given that prior to PCIP (effective date 12/1/11) I hadn't had health insurance in years so I don't have well documented medical history or doc appts within the past several years to document weight history or physician supervised dieting.
In your experience, without that kind of documentation (or much in the way of diet/gym receipts I keep reading about), do inscos reconsider?
The one thing I hope I can document is that I had severe anemia in 2003 (2.5 years after RNY), had a hysterectomy that did not correct it, had all kinds of oral iron and infusions that didn't correct it and was told that I had to eat a lot more red meat and other iron rich foods, which ultimately did correct it.
My BMI is now 50.7 I went for a physical in January, learned I have high BP, raging Diabetes despite a low carb lifestyle. So far the meds aren't working. Dr. K is pretty clear that the meds will do nothing but cause me to gain another 50lbs. NOT acceptable! My first priority is to regain my health.
I want to be on the other side of this revision soon and I CAN do it without insurance. It'll clean me out financially for now, but if that's the definitive and expedient answer, then so be it.
Your thoughts and any resources you are familiar with that might help me make this decision and/or appeal the insco's first denial would be sooo welcome.
Thanks so much for taking the time to read.
I hope I can return the favor in some way!
Liria
-----------------
I couldn't find your post - I'd appreciate it if you could repost my answer there, so others can benefit from it.
First of all, IF your insurance plan is regulated by the CA Dept. of Managed Health Care, this should not be an issue. But I don't know whether it is, since I'm guessing PCIP is the mandated health coverage program. PLEASE find out what your right of appeal is, ASAP.
Second, I think you can make a compelling story about not having had health care to prove what your medical condition has been in previous years. Just write it up.
As for documenting mechanical failure vs. patient failure, that is Dr. K's job. He needs to explain why your surgery needs to be fixed. He's pretty good at that. BUT PLEASE - ask him NOT to send anything in to your insurance company without letting you review his draft (we saw a recent letter of his which was apparently NOT reviewed by him after dictation and it was HORRIBLE with typos, errors, incomplete and illogical sentences) AND without you sending it to me and Lorraine (Larra) - we work as a team to help people get insurance coverage for the DS. In the meantime, please send me an email that includes this PM thread, along with explicit permission to include Lorraine in the conversation - PM is an impossible way to communicate. dianahc@comcast.net
Your documentation of having been given instructions to eat a certain way to address your anemia, which instruction may have been in conflict with how to maintain your RNY results, should be very helpful - they cannot say you were not compliant, if you were instructed to do this and did. And then we can argue that this is yet another compelling reason for revision to DS, because the diet you need to prevent anemia is the same diet that is recommended for DSers.
I believe you qualify AS IS for the DS - but your insurance company is simply trying to discourage you. We might be able to get them to retract the denial after one appeal, but be prepared to have to go all the way to external review.
-------------------
