CARDIO STRESS TEST MONDAY - CROSS POST

Hi All,

Just wanted to let everyone know the status of my RNY revision journey.  Saw Dr. Crookes at the beginning of the year, had another endoscopy, he also tested for gastric refulux, and the last stage is to undergo the cardio stress test.  After the cardio stress test is completed, I believe Dr. Crookes will write an advocacy letter to the insurance company and then we shall see if I'm approved.  The nurse coordinator warned me that a lot of the insurance carriers are not covering revision surgeries.  I am hoping for the best, but want to prepare for a denial of my request for revision surgery.  My basic problem is I am still relatively healthy for an obese person, and although my stoma and pouch are enlarged the insurance carrier may not want to approve my surgery request.  The next step would be to appeal it.  Any helpful suggestions about the appeal process in California would be appreciated.  I've also considered hiring a law firm to assist in the appeal. 

Hey Sweetie,
I have no advice but wanted you to know that you are in my thoughts. 
Lola :-)

Thanks L !!  U R such a sweetie.   Maybe I will see U at the support group mtg on Tuesday. 

Good luck on your stress test!

I've been through the appeal process (not for a revision, but for a DS) and went all the way through to the State Department of Managed Health Care and won. If I can be of any assistance, please let me know. I think whether or not you're approved will really be dependent upon which insurer you have. I have a lot of experience with "the Blues" - Blue Cross, Blue Shield and BC/BS, and with HealthNet/Wellpoint.

Good luck again, and keep your chin up!

My insurance is Blue Shield of CA.  Keep your fingers crossed.  If I get denied, I will be contacting U. 

Lots more information is needed. What kind of revision are you seeking? Doubtful it's off-label or out of the ordinary with Crookes.

Are you insured via your employer and are they self-insures (funded), or are you in a group HMO or on PPO plan? You need to acquire IN WRITING a detailed explanation of your benefits in this regard, Including any written exclusions. NEVER EVER accept what you are told over the phone. Employer self-funded managed plans require a different approach. Absent some iron clad written exclusion, If you under an HMO and some PPOs, you're likely in a better position for appeals if necessary.

In "general" the qualifications for revisions absent some demonstrable mechanical failure or other related sequella are much the same as for any WLS. BMI of = > 40 or = Or = > 35 with one or more significant comorbidites. 

If denied, depending on your insurer, plan, etc... you can expect to meet your internal appeals processes in a timely way and ultimately end with an external appeal with the CA Dept. Of Managed Care.,They are very proconsumer and especially pro the Duodenal Switch.


http://www.dmhc.ca.gov
email: [email protected]
California HMO Help Center
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
Phone: (888) HMO-2219 or (800) 400-0815
Fax: (916) 229-0465
TDD: (877) 688-9891

Again, this is generally applicable to HMOs here in CA and this does not constitute legal advice. Contacting DMHC may be helpful at this stage, but frankly, too much is lacking in your query to know how you should best proceed.

Rock

Just wanted to add mostly for the benefit of others, and certainly not likely your issue, I was much too large at 402 lbs. to do the typical cardiac stress test on the provided treadmill. My consulting internist came up with a very high tech solution. Just step up and down on a single step stool in rapid procession such that I achieved the heart rate desired. I see a lot of folks similarly situated getting chemically induced cardiac stress tests ordered without otherwise medical indications or risk factors.

Wasn't fun, but passing it with this novel approach didn't suck.

Rock

Rock,

Thanks for the advice. I will be an RNY revision.  I had the normal stress test and passed (YAY!).   I just spoke with Dr. Crookes' offc and they will be submitting to my PPO carrier the authorization request, diagnosis is acid reflux disease, weight regain, and throwing in a hernia for good measure.  If I get a denial, I will certainly appeal - so thanks for the info.