Need help with a letter for Revision Surgery

Hi Everyone,
Met my PCP today who was more than happy to refer me to a Bariatric Surgeon, however, his hands are tied since the Surgeon I want to see (Rabkin) is out of network.

I spoke with my Insurance Company Paciifcare HMO and they gave me a list of surgeons they do work with, non that I can tell perform a DS, yet there is no limitiation in the policy that states a DS isn't covered.  The ones they contract with are Mary Estakhri, Pamela Foster, Yen Chung (Andre) Lee, Dat Tien Nguyen, and Albert Wetter who was my original RNY surgeon.

Rabkins office suggested we pull as much info together as we can including Initial Consultation which is on Wednesday and I'll self pay, the original Surgical notes from Wetters office, the labs I'm having done tomorrow, etc.  Rabkins office said the appt. would take 3 to 4 hours. 

From there Pacificare said we should submit the information to the Medical Director at Pacificare and see if they'd be willing to cover.  They said I should also include a letter as to why I think I need a DS versus an RNY revision and have the surgeon include it with his recommendation, she said that way if you're denied, everything will be together if you choose to appeal.   They also said I should mention I'd be willing to self pay above and beyond the rate they contract with the Surgeons they do contract with.

Rabkins office said they haven't had much luck with HMO's recently but if I was willing to fight it, they'd help.  So, I'm ready for the battle -

If any of you have a similiar letter that you've had to write, can you send it my way?  I have also posted this on the DS and Revision Boards.

Thanks,
Debbie

Hi Debbie, I had a revision and I have Pacific  Care HMO. I went to Dr Higa in Fresno. He is a wonderful surgeon and does all kinds of WLS. I did not have to write a letter the Dr  took care of everything. I did have to jump through all the same hoops I did for the original wls.

Hi Cathy,

Was Dr. Higa in network for you?  I don't think I'd have a problem revising my RNY but I want to switch to a DS and there's no one in Pacificare's Network that does it here.

What did they site as the reason for you needing a revision? 

 

Thanks,
Debbie

Yes he is in the network. He has done lots of revisions and they vary with the patient as to what he does. He is easy to talk to and will listen. My stoma was to large, streched or whatever, the food just went right through so I was hungry all the time and gaining weight. He add a lap band to me and it is working pretty well although I do have a problem getting the right fill. Call his office and see if he is in your network. You will not be disappointed with him he is one of the very best surgeons.

GOOD MORNING MISS CATHY

Good Morning Firecracker I see you haven't figured out the picture thing yet lol.