Re: I WON!!! And I didn't even have to chew out their livers!

[Guest guest]

Congratulations ! Good luck on your procedure and I am glad to hear

that the individual case basis works better because that will be my argument!

Thanks for the tips! Ann

[Guest guest]

> Yep, it's official.

>

> After my second-level medical appeal on Tuesday, someone from

> the review committee called to let me know that, instead of my

> insurance company paying for the D/S under my out-of-network

> coverage option, THEY WILL PAY FOR MY SURGERY AS THOUGH IT WERE

> IN-NETWORK BECAUSE NO D/S SURGEONS OPERATE WITHIN MY AREA! WOO

> HOO! This means that I don't have to pay my deductible OR my

> $1000.00 maximum-out-of-pocket copayment!

CONGRATULATIONS, !!! That is wonderful! I'm so pleased for

you. It's always so heartening to read when someone wins on appeal.

> I have found that trying to argue academically about how the

> D/S is a better surgery than the RNY DOES NOT WORK. First of

> all, I'm barely equipped to do it, but more importantly, it IS

> an academic argument. I've gotten much farther with everyone

> involved by arguing about my specific and individual case. I

> hope that some of you can help me come up with more RNY

> contraindications. We could compile a list of persuasive items

> and keep it in the " files " section of this list and the D/S

> insurance list.

, what a fabulous idea! I'm sure a great many people would

find it helpful.

Again, congratulations on your win!

[Guest guest]

In a message dated 12/14/01 12:30:10 PM Eastern Standard Time,

duodenalswitch writes:

<< They also agreed to pay for my EGD (the procedure that I was stupid

enough to say was a preoperative <read: screening> procedure) but I

had to do some FAST backtracking with that one! All kinds of crap

about how my mild, chronic gastritis was probably owing to a patulous

lower esophageal sphincter and pylorus, and on, and on >>

Good news !!! Congratulations! I have a question about how you

proceeded with the above. Did you get an order from Dr. G. for the EGD

saying you had gastritis, therefore the egd, or did you just tell the egd doc

that is why you were having it done? My insurance won't pay for it pre-op,

but will if I have reflux, so I tried to get in touch with Dr.G's staff to

see about getting an order and no one was available to talk to. Please let

me know how this works. Did you get your approval before you had the EGD? I

thought all that stuff has to be done before they will send in the paper work.

Pam

[Guest guest]

,

I am so thrilled for you. I think your arguements are brilliant and I

would like to utilize them on Dr. Jossarts message board for defense

against insurances that only authorize the rny with your permission!

I also think if we could expand on this list as you suggested, it

could only help those who are still fighting the good battle. I would

love for you to add these arguements to the DS insurance board and I

would like to forward these to my surgeon so he can incorporate some

of these within the initial LOMN he uses for authorization!

Damn girl, I am so excited and think your approach was fantastic!

Huge hugs from your switch sister,

Theresa

Surgery date: DS Nov. 19, 2001

Dr. Gregg Jossart

Highest weight: 293

Surgery weight: 251

Current weight: 224

Height: 5' 7.5 "

> Yep, it's official.

>

> After my second-level medical appeal on Tuesday, someone from the

> review committee called to let me know that, instead of my

insurance

> company paying for the D/S under my out-of-network coverage option,

> THEY WILL PAY FOR MY SURGERY AS THOUGH IT WERE IN-NETWORK BECAUSE

NO

> D/S SURGEONS OPERATE WITHIN MY AREA! WOO HOO! This means that I

> don't have to pay my deductible OR my $1000.00 maximum-out-of-

pocket

> copayment!

>

> They also agreed to pay for my EGD (the procedure that I was stupid

> enough to say was a preoperative <read: screening> procedure) but I

> had to do some FAST backtracking with that one! All kinds of crap

> about how my mild, chronic gastritis was probably owing to a

patulous

> lower esophageal sphincter and pylorus, and on, and on. Lastly,

they

> will pay for all of my follow-up visits with Dr. Gagner as long as

> they follow a set time schedule, eg. 3 months, 6 months, 12 months,

> etc. Man, that EGD would have cost me another $1500.00 at least,

> and, well, we KNOW what Gagner charges!

>

> So, then. My 3 arguments for needing the D/S instead of the RNY

> worked! (1. Already have stomach problems; RNY's ulcer-producing

> tendency would exacerbate them. 2. Taking my large and frequent

> doses of non-steroidal anti-inflammatories to control pain is

> contraindicated with the RNY. 3. Anxiety/panic disorder would be

> exacerbated with RNY because " dumping " produces similar symptoms.)

> I have found that trying to argue academically about how the D/S is

a

> better surgery than the RNY DOES NOT WORK. First of all, I'm

barely

> equipped to do it, but more importantly, it IS an academic

argument.

> I've gotten much farther with everyone involved by arguing about my

> specific and individual case. I hope that some of you can help me

> come up with more RNY contraindications. We could compile a list

of

> persuasive items and keep it in the " files " section of this list

and

> the D/S insurance list.

>

> Cheers,

>

[Guest guest]

Hey, Pam.

I went into my PCP and told her to order an EGD for me because my

surgeon wanted it. STUPID! She listed no medical indications for

it, so my insurance company denied payment. The reason I went

through my PCP is because I was doing the NYC surgery preparations

from my home in Virginia, so I didn't bother Gagner's office because

he'll only order stuff that's gonna be performed in NYC.

My advice: develop some kind of medical reasons that indicate that

you need an EGD and/or have your PCP assist in writing things up for

you in the proper manner. I would say this to my PCP if I had to do

it all over again: " Look, Doc, I've been taking so many of these

Pepcid ACs for years and I'm getting tired of it. Not only that, but

now I'm thinking of having the D/S and I'm really worried about

what's going on down there. I'd like you to order an EGD (with or

without h. pylori biopsy) because my heartburn has not responded well

to this medicine as of the last few months. Yes, I know that I

should try some prescription stuff for reflux, but since I'm gonna be

having this surgery soon, I really don't want to wait for a trial

period of this medication. " Then stress that you need to make sure

that she writes up the request in a way that insurance will pay for

the procedure.

Best,

> In a message dated 12/14/01 12:30:10 PM Eastern Standard Time,

> duodenalswitch@y... writes:

>

> << They also agreed to pay for my EGD (the procedure that I was

stupid

> enough to say was a preoperative <read: screening> procedure) but

I

> had to do some FAST backtracking with that one! All kinds of crap

> about how my mild, chronic gastritis was probably owing to a

patulous

> lower esophageal sphincter and pylorus, and on, and on >>

>

>

> Good news !!! Congratulations! I have a question about

how you

> proceeded with the above. Did you get an order from Dr. G. for the

EGD

> saying you had gastritis, therefore the egd, or did you just tell

the egd doc

> that is why you were having it done? My insurance won't pay for it

pre-op,

> but will if I have reflux, so I tried to get in touch with Dr.G's

staff to

> see about getting an order and no one was available to talk to.

Please let

> me know how this works. Did you get your approval before you had

the EGD? I

> thought all that stuff has to be done before they will send in the

paper work.

> Pam

[Guest guest]

OMG, Congrats to you, !!!!!! Good for you!

BTW, who is your insurance company?

Yippeeee,

dee

--- mkfrilot wrote:

> Yep, it's official.

>

> After my second-level medical appeal on Tuesday,

> someone from the review committee called to let me

know that, instead of my insurance company paying for

the D/S under my out-of-network coverage option,

> THEY WILL PAY FOR MY SURGERY AS THOUGH IT WERE

> IN-NETWORK BECAUSE NO

> D/S SURGEONS OPERATE WITHIN MY AREA! WOO HOO! This

> means that I

> don't have to pay my deductible OR my $1000.00

> maximum-out-of-pocket

> copayment!

__________________________________________________

[Guest guest]

Dee,

My insurance company is QualChoice of Virginia (which was previously

owned by the University of Virginia, where I'm going to grad

school). QualChoice is being bought by Coventry Health, however, who

also owns Southern Health. Southern Health is based in Richmond and

QualChoice is taking on that name. From what I've read on the AMOS

site, Coventry and Southern Health are absolute bears to work with.

They fought to keep WLS out of their plans, but thanks to Virginia

state law, they now have to offer it but almost always? try to deny

benefits. I'm glad I got it before the official change takes place!

> > Yep, it's official.

> >

> > After my second-level medical appeal on Tuesday,

> > someone from the review committee called to let me

> know that, instead of my insurance company paying for

> the D/S under my out-of-network coverage option,

> > THEY WILL PAY FOR MY SURGERY AS THOUGH IT WERE

> > IN-NETWORK BECAUSE NO

> > D/S SURGEONS OPERATE WITHIN MY AREA! WOO HOO! This

> > means that I

> > don't have to pay my deductible OR my $1000.00

> > maximum-out-of-pocket

> > copayment!

>

> __________________________________________________

>

[Guest guest]

In a message dated 12/14/01 8:27:51 PM Eastern Standard Time,

duodenalswitch writes:

<< My advice: develop some kind of medical reasons that indicate that

you need an EGD and/or have your PCP assist in writing things up for

you in the proper manner. >>

Thanks, , but I already approached my PCP and they won't get involved

since I need this for the surgery. I guess I already messed up by asking

them. Maybe I will try it again on Monday after I have had time to stew

about it for a little bit. My pcp did give me an order for the thyroid tests

though, because I am hypothyroid and have been off my meds for that for a few

weeks.

Pam

[Guest guest]

Michele

Congratulations thats wonderful!

M.

pre-op 01/09/02

---------------------------------

[Guest guest]

My PCP sounds like yours. What did I do? I LIED! I don't know if

she knew that I was lying but I figured she was more comfortable not

knowing the truth. So go in with the Pepcid AC excuse. Say to

her " You know, here's something else I didn't tell you about . . .

this should be a proper medical indication for my EGD, right? "

> In a message dated 12/14/01 8:27:51 PM Eastern Standard Time,

> duodenalswitch@y... writes:

>

> << My advice: develop some kind of medical reasons that indicate

that

> you need an EGD and/or have your PCP assist in writing things up

for

> you in the proper manner. >>

>

> Thanks, , but I already approached my PCP and they won't

get involved

> since I need this for the surgery. I guess I already messed up by

asking

> them. Maybe I will try it again on Monday after I have had time to

stew

> about it for a little bit. My pcp did give me an order for the

thyroid tests

> though, because I am hypothyroid and have been off my meds for that

for a few

> weeks.

>

> Pam

[Guest guest]

, good for you that you got in in time and

that VA has that law - I wish CA did!

dee

--- mkfrilot wrote:

> Dee,

> My insurance company is QualChoice of Virginia

> (which was previously owned by the University of

Virginia, where I'm going to grad school). QualChoice

is being bought by Coventry Health, however, who also

owns Southern Health. Southern Health is based in

Richmond and QualChoice is taking on that name. From

what I've read on the AMOS site, Coventry and Southern

Health are absolute bears to work with. They fought

to keep WLS out of their plans, but thanks to Virginia

state law, they now have to offer it but almost always

try to deny benefits. I'm glad I got it before the

official change takes place!

>

>

>

>

> > > Yep, it's official.

> > >

> > > After my second-level medical appeal on Tuesday,

> > > someone from the review committee called to let

> me

> > know that, instead of my insurance company paying

> for

> > the D/S under my out-of-network coverage option,

> > > THEY WILL PAY FOR MY SURGERY AS THOUGH IT WERE

> > > IN-NETWORK BECAUSE NO

> > > D/S SURGEONS OPERATE WITHIN MY AREA! WOO HOO!

> This

> > > means that I

> > > don't have to pay my deductible OR my $1000.00

> > > maximum-out-of-pocket

> > > copayment!

> >

> > __________________________________________________

> >

[Guest guest]

I would love it if California could get some legislation going

regarding obesity surgery. I know the lobby in California is tough,

but I bet between Jackie Spear and Madams Feinstine and Boxer we

could get some support! Just a thought.

Hugs,

Theresa

Surgery date: DS Nov. 19, 2001

Dr. Gregg Jossart

Highest weight: 293

Surgery weight: 251

Current weight: 224

Height: 5' 7.5 "

> > > > Yep, it's official.

> > > >

> > > > After my second-level medical appeal on Tuesday,

> > > > someone from the review committee called to let

> > me

> > > know that, instead of my insurance company paying

> > for

> > > the D/S under my out-of-network coverage option,

> > > > THEY WILL PAY FOR MY SURGERY AS THOUGH IT WERE

> > > > IN-NETWORK BECAUSE NO

> > > > D/S SURGEONS OPERATE WITHIN MY AREA! WOO HOO!

> > This

> > > > means that I

> > > > don't have to pay my deductible OR my $1000.00

> > > > maximum-out-of-pocket

> > > > copayment!

> > >

> > > __________________________________________________

> > >