Guest guest Posted April 19, 2001 Report Share Posted April 19, 2001 Dear Janice, I'm sorry I can't help you. I am fighting the same battle with Cigna Healthcare of Ohio. If you come across any really good ideas on how to argue the out of network problem, let me know! And I'll keep an ear to the ground for you too. Best of luck and keep fighting. Angel --- Finch rfinch@...> wrote: > Hello, > PLEASE,I am asking for help to anyone who has > or knows of someone who > has been approved for the DS surgery through > Pacificare AND anyone who has > had or is seeking a revision to a DS from VBG or > RNY. Please email me > privately at rfinch@... so that the > support group wont have the > extra letters. I am trying to compile a list of > patients that have been > approved for the DS procedure to help support my > claim that Pacificare does > in fact cover this surgery. Also I need the list of > patients who have or > has had revision to a DS from VBGs and RNYs to use > as ammunition to prevent > Pacificare from giving me these surgeries (which are > in network) instead of > the DS (out of network) which I want. The more > names the better. For those > with revisions I would appreciate, if possible, your > letters giving some of > your problems and why you sought revision to DS so > that I may make copies of > these letters to add weight to my position. If you > would prefer for me to > use your name only that would be fine. I am at my > third level of appeal > and am in great need of this ammunition. The > biggest problem I face is > having to go out of network so if anyone has any > ideas to help with getting > insurance to help approve out of network I would > love to hear about them. > If I am successful I have all my letters I have used > for my doctor and > insurance company that I will be most happy to share > with everyone. I > figure no one wants to see them if I lose the fight, > but I must keep a > positive outlook. > I thank you for helping me. > Janice in Texas > > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 21, 2001 Report Share Posted April 21, 2001 Dear Shirley, I tried to take a " shortcut " and went right to my pcp and got her to send a letter of referral. She did, and my insurance co. agreed to my having WLS, however they wanted me to have the RNY because the Dr's were in network. As I've tackled this problem I've sent tons of letters to my insurance co. and did alot of phone calling to them. What I have found out to date is that what I gave them they are using to decide if they will even approve me for a consultation (paid for by the insurance co.) Then if they do,I can go to Dr. Hess (my surgeon of choice) and he will supply them with a " plan of action " , they will review it and give me the final ok. Tammy, (my personal contact at the insurance co)said if I was denied and I wanted to pay for the consult, then have Dr Hess send in his plan and send in any other Dr's or specialists letter of referral also. The more the merrier. She seemed helpful and now it's just a waiting game to see if I'll get a referral. If you are seeing any other Dr. for ANYTHING that might relate in some way to your obesity or co-morbidities, get letters from them! I even included pictures of myself (I figure a picture is worth a thousand words). Hope this helps. Feel free to e-mail me privately at angelquilt1@... if you want or need anything. Good luck, Angel --- Finch rfinch@...> wrote: > Hello Shirley, > My fight started when my PCP requested a > referral to go out of network > for the DS surgery consult. My > insurance-PacifiCare- decided that " yes " , I > could have WLS but needed to stay in network and > sent me to a VBG doc. I > then said " NO Way " and came back with how the DS and > its quality of life > issues fit me so much better than the VBG and RNY. > They turned deaf ears to > me and upheld their original denial to go out of > network. The issue here > is that they ARE allowing me WLS but not the one I > want which is out of > network. Since your PCP has already sent in a > referral for you then your > fight may start ASAP as well. If you can wait and > have a surgeon on your > side to fight with you or for you then that may be > the best way. Many of > the surgeons already know what the insurance > companies need for approval and > will write your Letter of Medical Necessity tweaked > to their requirements. > Read the NIH standards and required patient profile > for WLS and then make > sure you fit that pattern in any of your > correspondence. > For your DS folder, concentrate on what > specific changes are found in > the DS surgery over the others....such as what the > pyloric valve does, what > the duodenum does, how the malabsorption portion > benefits us and all this > can be found on the Duodenal Switch web site. What > might be a benefit to > one person may not be for another (like some people > feeling the 'dumping' > found in the RNY is a 'good' thing for them but this > is not for others) > though the site will give you wonderful hard and > fast reasons the DS is our > surgery of choice. What I need, and probably would > benefit others, is going > slightly beyond the well publicized differences and > finding those > individualized medical ramifications of this surgery > over the other surgical > types, such as needing the duodenum for breaking > down the OTC pain relievers > which I have mentioned before in another post. I > need all the help here I > can get. > If all your efforts fail in your struggle to > get the DS surgery you > need to consider your alternatives. For me, I will > contemplate the distal > RNY that you mentioned but I keep leaning away from > it. I am worried that > the problems of the malabsorption portion will not > be balanced by the small > pouch left for the stomach. If anyone has any ideas > along this line I would > love to hear them.There were a few posts in the past > that mentioned this and > it really seemed to make since. This is because, > for me, I do not want to > rely on liquid protein to get my protein needs in > and that is what a distal > RNY would probably have to do. The DS appears to be > able to get all their > protein needs in their normal food intake. Of > course this is information I > have gleaned from research and posts and in no way > am telling you that I put > it together 100% correct. My true hope is that I > can put away enough money > to go to Dr. Baltazar in Spain if my efforts fail > here with my insurance > company. This has been the choice for many. > Good luck and absolutely you can be in 'the > loop' if you still wish, > just stay tuned to this support group. Any outside > info I will be happy to > send. > Janice in Texas > > Re: Calling for Help > > > > Angel. Annette & Janice, > > > > PLEASE include me in any exchange of information > you have in trying > > to get a network to send you out of network. > > I have Kaiser and am also going to have a fight on > my hands to get > > the DS. I don't even really know where to begin. > I don't know when > > to approach the subject. My pcp has sent a > referal for me to have > > gastric bypass. My first step is to attend a 10 > week class with the > > dietition. My first of which will start on > Monday. Then I guess if > > I pass that they will let me talk to the > psychiatrist and then go to > > see the surgeon. My thinking is that I should > wait until I get to > > the surgeon and then tell him I only want the DS > and try to convence > > him to recommend it for me. I hate to waist all > the time going to > > all the classes and waiting for appointments > (sometimes that takes a > > couple of months) if there is no change to get the > doctor to help. I > > am wondering if this is the way to go or if there > is a better way. I > > just don't know what I am suposed to be doing > here. > > I have started my folder of reasons the DS is a > better choice for me, > > but sadly there is not much in there yet. I think > the idea of > > letters from people seeking a revision is a great > idea, and I would > > also like to include those in my folder. Although > they will probably > > argue that theese people did not have the RNY > Distal. They probably > > think that the Distal RNY will be just as good as > the DS, because > > like Janice said they are not concerned about our > quality of life, > > they are only concerened with saving them money > down the road. > > Please you guys (or anyone else) send me any > information you have > > that may help or anything that I might add to my > folder. You can > > send this to me privately. > > Thank you, > > Shirley > > P.S. I have a bmi of 68 and this should help but > I am not sure how. > > > > ---- > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 21, 2001 Report Share Posted April 21, 2001 Dear Shirley, I tried to take a " shortcut " and went right to my pcp and got her to send a letter of referral. She did, and my insurance co. agreed to my having WLS, however they wanted me to have the RNY because the Dr's were in network. As I've tackled this problem I've sent tons of letters to my insurance co. and did alot of phone calling to them. What I have found out to date is that what I gave them they are using to decide if they will even approve me for a consultation (paid for by the insurance co.) Then if they do,I can go to Dr. Hess (my surgeon of choice) and he will supply them with a " plan of action " , they will review it and give me the final ok. Tammy, (my personal contact at the insurance co)said if I was denied and I wanted to pay for the consult, then have Dr Hess send in his plan and send in any other Dr's or specialists letter of referral also. The more the merrier. She seemed helpful and now it's just a waiting game to see if I'll get a referral. If you are seeing any other Dr. for ANYTHING that might relate in some way to your obesity or co-morbidities, get letters from them! I even included pictures of myself (I figure a picture is worth a thousand words). Hope this helps. Feel free to e-mail me privately at angelquilt1@... if you want or need anything. Good luck, Angel --- Finch rfinch@...> wrote: > Hello Shirley, > My fight started when my PCP requested a > referral to go out of network > for the DS surgery consult. My > insurance-PacifiCare- decided that " yes " , I > could have WLS but needed to stay in network and > sent me to a VBG doc. I > then said " NO Way " and came back with how the DS and > its quality of life > issues fit me so much better than the VBG and RNY. > They turned deaf ears to > me and upheld their original denial to go out of > network. The issue here > is that they ARE allowing me WLS but not the one I > want which is out of > network. Since your PCP has already sent in a > referral for you then your > fight may start ASAP as well. If you can wait and > have a surgeon on your > side to fight with you or for you then that may be > the best way. Many of > the surgeons already know what the insurance > companies need for approval and > will write your Letter of Medical Necessity tweaked > to their requirements. > Read the NIH standards and required patient profile > for WLS and then make > sure you fit that pattern in any of your > correspondence. > For your DS folder, concentrate on what > specific changes are found in > the DS surgery over the others....such as what the > pyloric valve does, what > the duodenum does, how the malabsorption portion > benefits us and all this > can be found on the Duodenal Switch web site. What > might be a benefit to > one person may not be for another (like some people > feeling the 'dumping' > found in the RNY is a 'good' thing for them but this > is not for others) > though the site will give you wonderful hard and > fast reasons the DS is our > surgery of choice. What I need, and probably would > benefit others, is going > slightly beyond the well publicized differences and > finding those > individualized medical ramifications of this surgery > over the other surgical > types, such as needing the duodenum for breaking > down the OTC pain relievers > which I have mentioned before in another post. I > need all the help here I > can get. > If all your efforts fail in your struggle to > get the DS surgery you > need to consider your alternatives. For me, I will > contemplate the distal > RNY that you mentioned but I keep leaning away from > it. I am worried that > the problems of the malabsorption portion will not > be balanced by the small > pouch left for the stomach. If anyone has any ideas > along this line I would > love to hear them.There were a few posts in the past > that mentioned this and > it really seemed to make since. This is because, > for me, I do not want to > rely on liquid protein to get my protein needs in > and that is what a distal > RNY would probably have to do. The DS appears to be > able to get all their > protein needs in their normal food intake. Of > course this is information I > have gleaned from research and posts and in no way > am telling you that I put > it together 100% correct. My true hope is that I > can put away enough money > to go to Dr. Baltazar in Spain if my efforts fail > here with my insurance > company. This has been the choice for many. > Good luck and absolutely you can be in 'the > loop' if you still wish, > just stay tuned to this support group. Any outside > info I will be happy to > send. > Janice in Texas > > Re: Calling for Help > > > > Angel. Annette & Janice, > > > > PLEASE include me in any exchange of information > you have in trying > > to get a network to send you out of network. > > I have Kaiser and am also going to have a fight on > my hands to get > > the DS. I don't even really know where to begin. > I don't know when > > to approach the subject. My pcp has sent a > referal for me to have > > gastric bypass. My first step is to attend a 10 > week class with the > > dietition. My first of which will start on > Monday. Then I guess if > > I pass that they will let me talk to the > psychiatrist and then go to > > see the surgeon. My thinking is that I should > wait until I get to > > the surgeon and then tell him I only want the DS > and try to convence > > him to recommend it for me. I hate to waist all > the time going to > > all the classes and waiting for appointments > (sometimes that takes a > > couple of months) if there is no change to get the > doctor to help. I > > am wondering if this is the way to go or if there > is a better way. I > > just don't know what I am suposed to be doing > here. > > I have started my folder of reasons the DS is a > better choice for me, > > but sadly there is not much in there yet. I think > the idea of > > letters from people seeking a revision is a great > idea, and I would > > also like to include those in my folder. Although > they will probably > > argue that theese people did not have the RNY > Distal. They probably > > think that the Distal RNY will be just as good as > the DS, because > > like Janice said they are not concerned about our > quality of life, > > they are only concerened with saving them money > down the road. > > Please you guys (or anyone else) send me any > information you have > > that may help or anything that I might add to my > folder. You can > > send this to me privately. > > Thank you, > > Shirley > > P.S. I have a bmi of 68 and this should help but > I am not sure how. > > > > ---- > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 21, 2001 Report Share Posted April 21, 2001 Dear Shirley, I tried to take a " shortcut " and went right to my pcp and got her to send a letter of referral. She did, and my insurance co. agreed to my having WLS, however they wanted me to have the RNY because the Dr's were in network. As I've tackled this problem I've sent tons of letters to my insurance co. and did alot of phone calling to them. What I have found out to date is that what I gave them they are using to decide if they will even approve me for a consultation (paid for by the insurance co.) Then if they do,I can go to Dr. Hess (my surgeon of choice) and he will supply them with a " plan of action " , they will review it and give me the final ok. Tammy, (my personal contact at the insurance co)said if I was denied and I wanted to pay for the consult, then have Dr Hess send in his plan and send in any other Dr's or specialists letter of referral also. The more the merrier. She seemed helpful and now it's just a waiting game to see if I'll get a referral. If you are seeing any other Dr. for ANYTHING that might relate in some way to your obesity or co-morbidities, get letters from them! I even included pictures of myself (I figure a picture is worth a thousand words). Hope this helps. Feel free to e-mail me privately at angelquilt1@... if you want or need anything. Good luck, Angel --- Finch rfinch@...> wrote: > Hello Shirley, > My fight started when my PCP requested a > referral to go out of network > for the DS surgery consult. My > insurance-PacifiCare- decided that " yes " , I > could have WLS but needed to stay in network and > sent me to a VBG doc. I > then said " NO Way " and came back with how the DS and > its quality of life > issues fit me so much better than the VBG and RNY. > They turned deaf ears to > me and upheld their original denial to go out of > network. The issue here > is that they ARE allowing me WLS but not the one I > want which is out of > network. Since your PCP has already sent in a > referral for you then your > fight may start ASAP as well. If you can wait and > have a surgeon on your > side to fight with you or for you then that may be > the best way. Many of > the surgeons already know what the insurance > companies need for approval and > will write your Letter of Medical Necessity tweaked > to their requirements. > Read the NIH standards and required patient profile > for WLS and then make > sure you fit that pattern in any of your > correspondence. > For your DS folder, concentrate on what > specific changes are found in > the DS surgery over the others....such as what the > pyloric valve does, what > the duodenum does, how the malabsorption portion > benefits us and all this > can be found on the Duodenal Switch web site. What > might be a benefit to > one person may not be for another (like some people > feeling the 'dumping' > found in the RNY is a 'good' thing for them but this > is not for others) > though the site will give you wonderful hard and > fast reasons the DS is our > surgery of choice. What I need, and probably would > benefit others, is going > slightly beyond the well publicized differences and > finding those > individualized medical ramifications of this surgery > over the other surgical > types, such as needing the duodenum for breaking > down the OTC pain relievers > which I have mentioned before in another post. I > need all the help here I > can get. > If all your efforts fail in your struggle to > get the DS surgery you > need to consider your alternatives. For me, I will > contemplate the distal > RNY that you mentioned but I keep leaning away from > it. I am worried that > the problems of the malabsorption portion will not > be balanced by the small > pouch left for the stomach. If anyone has any ideas > along this line I would > love to hear them.There were a few posts in the past > that mentioned this and > it really seemed to make since. This is because, > for me, I do not want to > rely on liquid protein to get my protein needs in > and that is what a distal > RNY would probably have to do. The DS appears to be > able to get all their > protein needs in their normal food intake. Of > course this is information I > have gleaned from research and posts and in no way > am telling you that I put > it together 100% correct. My true hope is that I > can put away enough money > to go to Dr. Baltazar in Spain if my efforts fail > here with my insurance > company. This has been the choice for many. > Good luck and absolutely you can be in 'the > loop' if you still wish, > just stay tuned to this support group. Any outside > info I will be happy to > send. > Janice in Texas > > Re: Calling for Help > > > > Angel. Annette & Janice, > > > > PLEASE include me in any exchange of information > you have in trying > > to get a network to send you out of network. > > I have Kaiser and am also going to have a fight on > my hands to get > > the DS. I don't even really know where to begin. > I don't know when > > to approach the subject. My pcp has sent a > referal for me to have > > gastric bypass. My first step is to attend a 10 > week class with the > > dietition. My first of which will start on > Monday. Then I guess if > > I pass that they will let me talk to the > psychiatrist and then go to > > see the surgeon. My thinking is that I should > wait until I get to > > the surgeon and then tell him I only want the DS > and try to convence > > him to recommend it for me. I hate to waist all > the time going to > > all the classes and waiting for appointments > (sometimes that takes a > > couple of months) if there is no change to get the > doctor to help. I > > am wondering if this is the way to go or if there > is a better way. I > > just don't know what I am suposed to be doing > here. > > I have started my folder of reasons the DS is a > better choice for me, > > but sadly there is not much in there yet. I think > the idea of > > letters from people seeking a revision is a great > idea, and I would > > also like to include those in my folder. Although > they will probably > > argue that theese people did not have the RNY > Distal. They probably > > think that the Distal RNY will be just as good as > the DS, because > > like Janice said they are not concerned about our > quality of life, > > they are only concerened with saving them money > down the road. > > Please you guys (or anyone else) send me any > information you have > > that may help or anything that I might add to my > folder. You can > > send this to me privately. > > Thank you, > > Shirley > > P.S. I have a bmi of 68 and this should help but > I am not sure how. > > > > ---- > > > > > Quote Link to comment Share on other sites More sharing options...
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