1 year and two months later...revision....

tomickey
on 11/12/11 11:44 pm - Goose Creek, SC

As of today it has been 1year and two months since I had my Gastric Bypass Surgery. As today I have lost a total of 42 lbs. I noticed something was not right around my six months follow up when I had only lost approx. 32-36 lbs. My doctor did check to find out if I had a fistula... Which I did not. At my yearly visit they decided to recheck, things and realize that my pouch was not made small enough and they want to go back in to do a revision.
Yes, I have been following my diet plan regularly, the dietitian is not even worried about that part of me habits. I even go to the gym 3-4 days a week for at least two hours. So yes this journey has been frustrating!!!

The Dr.'s office sent my insurance company a request for revision, which they denied saying that, from their review I did not follow a proper diet and and over ate and stretched my stomach.
Now I'm not understand this because, ummm what proof do they have of this? You can not just place me under the class of this is what usually happens.... They did not request information nothing. So I'm looking to appeal their decision with the help of my Dr's office. I am suppose to write an appeal letter stating my case also but I do not know what to put in it.

Any help our suggestions with this? What or how shall I write this appeal letter?

poet_kelly
on 11/12/11 11:58 pm - OH

RNY on 11/04/08

I'm sorry you're dealing with this. How frustrating.

I would just write a letter telling them about the diet you follow. Maybe list some of the typical meals you ate, along with the amounts of food.

I'm assuming the doctor sent them something saying the pouch was made too large?

And can you ask them what they reviewed that showed you did not follow the diet?

Kelly

Please note: I AM NOT A DOCTOR. If you want medical advice, talk to your doctor. Whatever I post, there is probably some surgeon or other health care provider somewhere that disagrees with me. If you want to know what your surgeon thinks, then ask him or her. Check out my blog.

littleskie
on 11/13/11 12:11 am - freeport, TX

RNY on 08/19/09 with

Poetkelly's advice is sound. She is amazing and if you follow her directions you stand the best chance possible.

Good luck!

poet_kelly
on 11/13/11 1:40 am - OH

RNY on 11/04/08

I actually don't know that much about insurance. I'm just trying to be logical. And hopefully my advice helps, but I'm not making any promises.

Thanks for the compliment, though.

Kelly

Please note: I AM NOT A DOCTOR. If you want medical advice, talk to your doctor. Whatever I post, there is probably some surgeon or other health care provider somewhere that disagrees with me. If you want to know what your surgeon thinks, then ask him or her. Check out my blog.

Carol S.
on 11/13/11 12:33 am - Milwaukee, WI

RNY on 09/08/03

Insurance is a business, just like anything else and they don't want to lose money.

Document everything, your diet, your talks with the doctor, any communication with the insurance company and talk to them about appeals and how they work.

Good luck!

Carol

SW/276 CW 150 GW 185

9 Years out.

tomickey
on 11/13/11 1:10 am - Goose Creek, SC

RNY on 09/08/10

Thanks Everyone!! I will try this out!! Yes, I was thinking of sending them copies of my food diary basic a typical day of my life. we shall see what happens

poet_kelly
on 11/13/11 1:42 am - OH

RNY on 11/04/08

Yeah, I think that would good. But also make sure the surgeon has sent them something saying the pouch was made too large with the first surgery, that it was not stretched by overeating.

I wonder, if the issue is that the first surgeon made the pouch too big, if the insurance company should try to recoup some money from him. For that matter, you might have a malpractice case, if he did not perform the surgery correctly.

Kelly

Please note: I AM NOT A DOCTOR. If you want medical advice, talk to your doctor. Whatever I post, there is probably some surgeon or other health care provider somewhere that disagrees with me. If you want to know what your surgeon thinks, then ask him or her. Check out my blog.

Sunbunnyqt
on 11/13/11 2:29 am - FL

RNY on 10/12/11

Are you seeing a different surgeon than you had with the original surgery? I am amazed that it took this long for these questions to come up. I think the one thing you can do is to establish you were compliant with the original program. Do you have diabetes or any other medical condition you are dealing with?

tomickey
on 11/13/11 3:25 am - Goose Creek, SC

RNY on 09/08/10

I am seeing the same surgeon that did it . Yes, I was surprised that it took that long to notice. I am a diabetic when I was losing weight my H1Ac was getting better it went from 8.1 before surgery to an 5.6 after now it is back up to an 6.5. And swelling has started again in my ankles. I actually have gained 7lbs too.

poet_kelly
on 11/13/11 5:48 am - OH

RNY on 11/04/08

So your surgeon is telling you that he did not make the pouch as small as he should have? Then why isn't he fixing his mistake for free?

But are you sure you really trust him to make it the right size this time?

Kelly

Please note: I AM NOT A DOCTOR. If you want medical advice, talk to your doctor. Whatever I post, there is probably some surgeon or other health care provider somewhere that disagrees with me. If you want to know what your surgeon thinks, then ask him or her. Check out my blog.

1 year and two months later...revision....

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1 year and two months later...revision....