Shelli,



Big HUGS to you!!!!  Keep on fighting!!!!  I am in the middle of the long and difficult fight.  IT SUCKS, but I am trying to hang in there!!!!!



You will win your appeal, and soon will be posting your surgery date!!!!!
-Jamie

I don't think it would be THAT much of a challenge if, and I don't know about your particulars, can convince them that you are NOT a good candidate for the other options.

We already know the band is out.  You can probably talk them down from the sleeve since it, too, is "only restrictive" and you have not done well with a restrictive surgery.  That leaves the RnY...and I'm sure if you documented all the reasons you should NOT have the RnY...because of your arthritis or fibromyalgia or some hx of knee or hip problems and a need to take NSAIDS for the rest of your life...that kind of thing...they would have to offer you the remaining option.

Unfortunately, I had to delete this post due to privacy concerns.

Unfortunately, I had to delete this post due to privacy concerns.

I feel your pain.  When my kid decided she wanted breast reduction surgery, she had Aetna.  She went to FIVE in network plastic surgeons and they all recommended approximately the same amount of removal.  Aetna denied it because their in-house guy decided that she practically had to become flat-chested in order for them to pay for the surgery.

I wrote a scathing letter (consensus is that I'm meaner) in which I mentioned, among other things, that five out of five of their in-network board certified plastic surgeons had come to ONE conclusion and their in-house expert...who (which I discovered when I looked him up) was a board certified otolaryngologist who had retired ten years ago...was odd man out.  I asked if they REALLY wanted to make fools of themselves at a State Department of Insurance Review...and what do you know...I had misunderstood their denial to mean that they were DENYING the service, when in fact, they meant they would cover it.

She went from a 36 J--as in Jumbo--to a dainty 36 C or D.

Look into the history of the person who is denying you.  S/he may have NO basis, in education or experience, to be making that decision...and the company needs to be told that to disagree with science and common sense does NOT make their position in any other denials of servie look any more reasonable.  (Nicely, of course.  Don't have me do it.)

And, while BCBSNC is in fact a different company than other BCBS organizations, I'd mention that they really are no more in a position to define that a surgery that is fully covered by other firms is "investigational" than they do to declare that a hysterectomy is "investigational."

Did your insurance company provide EVIDENCE for asserting that the DS for BMI < 50 is investigational?  There are NO limits in the NIH guidelines; Medicare has no limits; I have not seen a single paper saying this, and there are papers saying the opposite, e.g.:

Surg Obes Relat Dis. 2010 Sep-Oct;6(5):508-14. Epub 2010 Mar 29.

Is biliopancreatic diversion with duodenal switch indicated for patients with body mass index

Unfortunately, I had to delete this post due to privacy concerns.

Diana....Does this mean that the state reviews denials of services?

"review Preferred Provider Organization(PPO) plans for compliance of non-financial operational policies and procedures;"

www.ncdoi.com/lh/lh_home.asp


Shelli...what does your policy tell your your appeal protocol is?

Unfortunately, I had to delete this post due to privacy concerns.

I don't have any experience with insurance, I just wanted to congratulate you on your tenacity in fighting this. You are not only helping yourself, but you are blazing a path that will help those who come behind you.

You are a hero.