Margy/ DS Approval Problem

[Guest guest]

Hi Margy,

I had this EXACT same problem. My insurance is an HMO and I knew by

looking at their list of participating providers that there were no

DS surgeons IN-plan. I chose a surgeon, in-state but out-of-network,

and made a consult appt, planning to self-pay for the consult if I

had to.

To make a long story short (you can check out the details in my AMOS

profile, link in signature line below, if you want). I got my denial

letter the *day before* I was scheduled to have surgery. I appealed

it and just found out Friday that my appeal was GRANTED!

The key, I think, in getting them to reverse their decision was

making them see that the BPD/DS is NOT the same as the RNY.

Apparently there is really only one set of insurance procedure codes

for the gastric bypass. There is no distinction between the

different forms. I got my PCP to send a letter explaining the

differences and why the BPD/DS was better suited to me.

I also had a referral/consult with an in-plan RNY surgeon. A month

after the visit, on a whim, I sent him a letter asking him to write

me a letter stating that the BPD is different from the RNY and that

he knew of no in-plan surgeons performing it.

You can email me privately if you would like sample copies of these

letters. Someone helped me by allowing me to use parts of their

letters and since they worked for me, I'd like to " return the favor " .

Hope this helps. Please know that it IS possible to win this one.

We are here for you.

Terri Hassiak

BMI 60

http://www.obesityhelp.com/morbidobesity/profile.phtml?N=H980366398

Appealed " Out-of-Network " Ins. Denial - AND WON!!!

email(no spaces): bunsofluff @ hotmail.com

> I'm hoping someone can give me some assistance. My PCP is all for

the

> DS surgery, and submitted the request to my insurance which is

> Lifeguard HMO here in Northern California. I expected them to deny

it

> and today I received the denial. They say they will not cover it

> because the DS doctor is outside of Lifeguard's network and that I

> need to see an in network surgeon. But of course, there aren't any

in

> network surgeons who do DS.

>

> What should my next step be? Should I just go ahead and appeal? I

> suspect that the next denial would be because they think the DS is

> the same as RNY and I should go to one of their RNY doctors.

> Or...should I try to figure out which insurance companies have paid

> for DS with the DS Dr I want and hope one of them is one I can

switch

> to next year? I do hate the thought of waiting that long.

>

> Has anyone had any luck getting insurance approval for DS outside

of

> their network?

>

> Sigh...

>

> Margy