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Post by 2011Mommy on Dec 23, 2011 11:50:42 GMT -5
I have my consult on the 4th and if all goes well, I will be submitting for approval next month. The requirements for a revision are listed below and without a doubt I meet criteria 1 and 3.
However, I am concerned about the “documentation of compliance with the previously prescribed postoperative dietary and exercise program”. How do I prove this? I have already requested my medical records from the doctor in the U.S. doing my fills. Is that enough? I can also get the medical records from my PCP to show I was on Phentermine on and off for a year- I’m not sure if that would help. In addition, I did 2 months of Medifast, went to another weight loss clinic for a couple months and met once with a private nutritionist.
Are any of these even relevant? By the way, the DS is covered! ;D
I appreciate the help!!!
“Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss, (i.e., unrelated to a surgical complication of a prior procedure) are considered medically necessary when all the following criteria are met:
• 1)The individual continues to meet all the medical necessity criteria for bariatric surgery (see page 1); and
• 2)There is documentation of compliance with the previously prescribed postoperative dietary and exercise program; and `
• 3)2 years following the original surgery, weight loss is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight “
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Post by Deleted on Dec 23, 2011 13:10:18 GMT -5
When you prepare your letter, you will create a section entitled "I meet the requirements for revision surgery" or something like that. There will be three subheadings, with the three requirements, and you will document how you meet them, with reference to your medical records. For the second item, you can include both pre-band and post-band efforts made to comply with diet and exercise, both with reference to your medical records of visits to get fills, and to things you did on your own - how you received instructions from the band surgeon, and did exactly what was required, when you started exercising, what you did and that you were diligent about it; the appetite meds you were prescribed when the band didn't help like it was supposed to, nutritionist appts (get copies of medical records and attach pertinent notes). Swamp them with evidence of your compliance - that should do it.
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Post by Deleted on Dec 23, 2011 13:38:40 GMT -5
And I wanted to add that requirements like this are both logical and insidious - the insurance companies certainly should have SOME sort of filter to prevent people from thinking of their WLS as "set it and forget it" surgeries, to put up a barrier to exploitation by patients who didn't even try; but at the same time, the insurance company knows that many patients will be so thoroughly discouraged by this requirement, because even if they DID make reasonable efforts to be compliant, they will feel guilty about their failure to stick to the extreme and superhuman measures required for ABSOLUTE compliance, that they therefore won't even TRY to assert their compliance.
The person who first reviews your request for revision will be looking for the most part for whether any effort was made to demonstrate that the patient meets all the requirements for revision; if there is SOMETHING reasonable presented to allow him/her to tick the box that the requirement has been met, it is possible or even likely that they won't delve further into your psyche about how honest with yourself and them you are being. Unless of course there is a reason, e.g., in your medical records, demonstrating that you were NOT compliant.
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Post by 2011Mommy on Dec 23, 2011 13:59:23 GMT -5
Thank you Diana. I was feeling discouraged about “proving” my efforts and your reply gives me hope that I have a good shot at getting approved.
By the way, I went on OH a few months ago to learn about revising to an RNY. So many of the problems RNYers experienced (getting stuck, etc) were the same ones I already had with the band and I was so scared to continue having these issues but in desperation I was willing to get the RNY. You posted on the board about the DS. I had never heard of it so I started to read all your posts (and went on DSfacts.com). I am so THANKFUL you posted- you have impacted my life more than you will ever know. Thank you!
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Post by lovy19 on Dec 23, 2011 19:21:38 GMT -5
And I wanted to add that requirements like this are both logical and insidious - the insurance companies certainly should have SOME sort of filter to prevent people from thinking of their WLS as "set it and forget it" surgeries, to put up a barrier to exploitation by patients who didn't even try; but at the same time, the insurance company knows that many patients will be so thoroughly discouraged by this requirement, because even if they DID make reasonable efforts to be compliant, they will feel guilty about their failure to stick to the extreme and superhuman measures required for ABSOLUTE compliance, that they therefore won't even TRY to assert their compliance. The person who first reviews your request for revision will be looking for the most part for whether any effort was made to demonstrate that the patient meets all the requirements for revision; if there is SOMETHING reasonable presented to allow him/her to tick the box that the requirement has been met, it is possible or even likely that they won't delve further into your psyche about how honest with yourself and them you are being. Unless of course there is a reason, e.g., in your medical records, demonstrating that you were NOT compliant. hi Diana, 2011 mommy and I have similar stories but my thing is after regurgitating from a few fills ( I won't lie and said I had a lot of them) I just gave up and stopped getting them I was tired of getting sick like that helped, i have been regurgitating ever since i got the band even without the fills, the only way to stop Is to eat the bad foods, this is why I think i will be denied because altough my BMI IS 41.1, suffer with high blood pressure been taking phentermne since 1994 - 2010 with medical weight nutritionist they may say I was not compliant, I guess I will have to wait and see. I'm preparing myself to be stuck with this band. |
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Post by cathy811 on Dec 24, 2011 0:48:39 GMT -5
Hi Lulu, are you blue cross of california? If so, then I have them as well and my case was submitted to insurance last week, I am waiting approval. I was not asked by Dr. K's office to "prove" anything and did not have to write a letter. I suppose if I have to appeal it should I get denied then maybe I'll have to write a letter.
Best of luck to you!!
Cathy
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Post by 2011Mommy on Dec 24, 2011 12:44:26 GMT -5
Hi Lulu, are you blue cross of california? If so, then I have them as well and my case was submitted to insurance last week, I am waiting approval. I was not asked by Dr. K's office to "prove" anything and did not have to write a letter. I suppose if I have to appeal it should I get denied then maybe I'll have to write a letter. Best of luck to you!! Cathy Yes, I have Blue Cross of California (PPO). This is yet another reason I want to at least consult with Dr. K. It sounds like the really take care of everything! Are you a revision as well? |
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Post by Deleted on Dec 25, 2011 0:08:23 GMT -5
When you prepare your letter, you will create a section entitled "I meet the requirements for revision surgery" or something like that. There will be three subheadings, with the three requirements, and you will document how you meet them, with reference to your medical records. For the second item, you can include both pre-band and post-band efforts made to comply with diet and exercise, both with reference to your medical records of visits to get fills, and to things you did on your own - how you received instructions from the band surgeon, and did exactly what was required, when you started exercising, what you did and that you were diligent about it; the appetite meds you were prescribed when the band didn't help like it was supposed to, nutritionist appts (get copies of medical records and attach pertinent notes). Swamp them with evidence of your compliance - that should do it. When I prepared the appeal letter for our daughter's denied breast reduction surgery, I went to the Aetna website and copied and pasted THEIR criteria into the appeal letter in a dark grey and changed the font color to black as I plugged in each of her numbers (all exceeding their minimum requirements) into their paragraphs. (The only point of debate after THAT was how much tissue had to be removed and I gently--yeah,right--mentioned that since FIVE board certified plastic surgeons in THEIR network were in agreement and the denial was authored by their in-house guy who seemed to be--according to records available on line--an ENT, I didn't think that getting the denial reversed would be a problem once we got to the state level.
Within a day or two, they decided that we had misunderstood the denial and it was actually an authorization and they'd resend it to make it more clear.) |
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Post by Deleted on Dec 25, 2011 0:10:54 GMT -5
I have my consult on the 4th and if all goes well, I will be submitting for approval next month. The requirements for a revision are listed below and without a doubt I meet criteria 1 and 3. However, I am concerned about the “documentation of compliance with the previously prescribed postoperative dietary and exercise program”. How do I prove this? I have already requested my medical records from the doctor in the U.S. doing my fills. Is that enough? I can also get the medical records from my PCP to show I was on Phentermine on and off for a year- I’m not sure if that would help. In addition, I did 2 months of Medifast, went to another weight loss clinic for a couple months and met once with a private nutritionist. Are any of these even relevant? By the way, the DS is covered! ;D I appreciate the help!!! “Repeat surgical procedures for revision or conversion to another surgical procedure (that is also considered medically necessary within this document) for inadequate weight loss, (i.e., unrelated to a surgical complication of a prior procedure) are considered medically necessary when all the following criteria are met: • 1)The individual continues to meet all the medical necessity criteria for bariatric surgery (see page 1); and • 2)There is documentation of compliance with the previously prescribed postoperative dietary and exercise program; and ` • 3)2 years following the original surgery, weight loss is less than 50% of pre-operative excess body weight and weight remains at least 30% over ideal body weight “ Anthem BC of CA--PPO paid for my band-to-DS revision with Keshishian. His office did all the paperwork. BTW, right AFTER I had the surgery they decided they didn't really MEAN that they had approved it...but I convinced them that they did. I was an alarming piece of mail, though. Just so you know that they do that kind of thing. |
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