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Sean_B's Blog
10/26/06 - waiting and fighting
well, my paperwork was submitted to insurance on 10/13. made a few calls to make sure everything was proceeding ok, and if they needed anything else that might be missing... get a letter in the mail on Monday 10/23 that I have been denied because their paperwork (which I don't doubt is probably written on original PAPYRUS) tells them that the DS is "Experimental and/or investigational" and that it is (check THIS out...) "not generally recognized by the medical community as effective or appropriate for the particular diagnosis or treatment of the covered person's particular condition as demonstrated by Reliable Scientific Evidence" well if I EVER read a crock of crap, THAT was it... ok... let's break that down a bit... the particular condition and diagnosis that I'm seeking treatment for is called "Morbid Obesity" The procedure I'm seeking approval for (the DS) was created by Dr Hess back in 1988 for the sole purpose of treating obesity. EVERY paper done on the DS reports on its efectiveness, and the effectiveness IS recognized by anyone in the medical community who is at least somewhat familiar with bariatrics. the ASBS, in 2003, wrote a resolution stating that "Whereas: Gastric Bypass, Vertical Banded Gastroplasty, Gastric Banding, Duodenal Switch and Biliopancreatic Diversion have withstood appropriate scrutiny through the literature and the experience of surgeons performing these procedures, in the spirit of the specific purpose of the ASBS of the interchange of ideas, information and experience pertaining to bariatric surgery" Then it goes on.... Whereas: The safety, efficacy and the benefit of the above procedures are well tested and established by such interchange... Therefore: Be it resolved that the society recognize the above procedures, whether performed open or laparoscopic, as appropriate and accepted remedies in the treatment of clinically significant obesity and its attendant comorbid conditions" so of course, I promptly filed an appeal (which I was already doing research for anyway). Monday afternoon, I dropped off at the post office to mail out my appeal package. Of course I included the above ASBS resolution... along with about 200+ other pages worth of similar literature... JAMA articles, various papers authored by such highly regarded surgeons as Hess, Anthone, Baltasar, Rabkin, Gagner, Keshishian, etc, etc. then just to top it all off... I included the WLS portions of various policies of national insurance companies... Aetna, various branches of BCBS, Unicare.. along with the MEDICARE policy on WLS... ALL include DS as an acceptable procedure. Speaking with the woman in the Pre-D dept at my insurance co, she actually seemed to be very nice and helpful. As she explained (and I SORT OF understand) she can only go by what is written in the procedure books they have there... but after reading a couple of the items that I sent, she "personally" agrees that I have submitted sufficient evidence... but that now it wasn't up to her, that it was being sent out for external review by a non-affiliated doctor (or doctors) who is familiar with bariatrics. Whether he/she LIKES the DS procedure or not should be irrelevant... only that evidence supports MY stance that the DS is NOT "experimental and/or investigational" of course I'm a LITTLE concerned with the final determination... but I'm confident that they can't really still make that E&I claim after being presented with the packet I sent... what I'm MORE concerned about, is whether they make final determination early enough that I can keep my originally scheduled 11/14 surgery date. I'm not into prayer... but I DO believe in positive energy (regardless of what you claim the source to be)... any positive thoughts you can aim in my direction would be appreciated. Thanks 2 Comment(s)
Comment by LeaAnn on Nov 22, 2006 at 02:38pm
Another atheist! YAY! lol!
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Did you see the appeal letter that Stary posted on the board. I thought it was very well written and you might be able to gather some extra info from it, if you need it.
Scott