Denied!!!! I WILL NOT GIVE IN!!!!
I posted this in my blog, and also X-posted on the revisions board too.
Got my denial letter yesterday from the insurance company (4/23/2011). I do know that they send the claims along to Medical Consultants to review. I will be calling my claims administrator in the morning regarding the "no documentation of my participation in a medically supervised diet" & fax all of that paperwork to her, and to get a copy of that determination from the Medical Consultants, that report has all of the details. The one thing that just irritates the **** out of me at the end of the letter is, yet again they state that there is NO DOCUMENTATION of me participationg in a medically supervised weight loss program??!!?? I HAND carried all of the documentation to my office visit in California with Dr. Keshishian. I have dug it all BACK OUT and I will be faxing it down to my Claims Supervisor first thing tomorrow morning!!!! UUUUUUGGGGGGGGGHHHHHHHHH ******g IRRITATING!!!! I have been on a medically supervised diet, with phentermine & monthly weigh in's well over 18 months!!!!!!!!!!!!! But in the mean time............
Here is what the insurance company says:
We fowarded your 3/24/11 request to preauthorize coverage for a revision from a failed gastric bypass to a gastric reduction/duodenal switch procedure to correct severe complications from from the previous procedure for Jamie (last name) to the medical consultant for the Alaska United Food & Commercial Workers. (a.k.a. Safeway) The consultant reviewed the documentation submitted with the current pre-authorization request and the documentation included with the previous request dated 10/25/10.
The reviewer's conclusion was that the surgery is not medically necessary. "The patient is 8 years status post Roux-en-Y gastric bypass. While her initial weight loss was very good, she has been unable to sustain that and has regained 85 pounds. The upper endoscopy identifies a healing marginal ulcer and the upper GI contrast study shows normal past gastric bypass anatomy. There is no documentation of attempts at treatment of the mariginal ulcer or that her low vitamin D level is refractory to conventional supplemental treatment. Finally, there is no documentation of this patient's participation in a medically supervised weight loss program. The avaliable documentation does not support that revisional bariatric surgery is medically necessary for this patient."
Consequently, we will not be about to allow benefits toward the proposed revision of the 2002 gastric bypass.
Please let me know if you have any questions, or if I can be of further assistance.
(Lady's name)
Claims Supervisor.
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
on 4/24/11 3:43 am, edited 4/24/11 11:50 am - Tuvalu
So, there's your list. All you now have t do is shoot a hole in each of them:
•While her initial weight loss was very good, she has been unable to sustain that and has regained 85 pounds.
•The upper endoscopy identifies a healing marginal ulcer and
•the upper GI contrast study shows normal past gastric bypass anatomy.
•There is no documentation of attempts at treatment of the mariginal ulcer
•or that her low vitamin D level is refractory to conventional supplemental treatment.
•Finally, there is no documentation of this patient's participation in a medically supervised weight loss program.
Sue,
YOU ROCK!!!!! The last thing on the list, well, I am thinking that they have it, but just using it as a stall technique. That will be taken care of tomorrow morning, as for the rest..... I am cluless on the marginal ulcer. I was told I had one. But???? Was never asked/told to treat it. I guess I will be working on that one as well.
Once I get the actual report from the Medical Review board that they hire (It has ALL the details & is usually around 4 pages). I will be working on that as well.
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
Ginger<><
Revision #2 Dr John Rabkin June 21, 2013; First Revision DS - Dr Maguire 5-18-09; First DS 7-15-2003 Dr Clark Warden = Third time is the charm 
Ginger,
I work with the Same Claim Supervisor, so makes my life easier. I will be contacting her in the morning, and I will be faxing all of the doctor supervised diet documentation over to her, and also requesting the report from the Medical Review board that they foward all of their pre-authorization requests to. That should give me a good start, at least.
Oh, ya, I am frustrated. I honestly did not have my hopes up for an approval......... I was witing on the actual paper that was going to say approval........ Then I would have jumped for joy!!!! Since this was my 3rd time, I was not to trusting in an approval.
Oh, you just gotta love the insurance "stall" techniques!!!!! Ha Ha Ha
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
Don't give up girlie - you gotta lotta fight left in you!
I'll keep sending up prayers that hopefully sooner than later you will get that approval letter you rightly deserve and can be on your way to the DS life....
Chin up girlie!
Kerry J 
Stillhopefull (Terry) is my Angel!!!! 
Angel to Baylady35310 (Linda)
7/9/01 RNY - 354 HW down to 192 LW
12/6/10 DS Revision - GW 170
DS HW 353
DS SW 332
DS CW 184 (-148 since surgery / -169 total)
Plastics completed by Dr.Sauceda in MX 8/9/13 - LBL w anchor cut, long thigh lift, breast lift, butt augmentation and arm lift.
This really was a "blow", but I was prepared as much as I could be for another denial. As SUCKY as this situation is!!!!
Tomorrow is another day to fight!!!!!!
THANKS!!!!
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
KAREN W.
I LOVE MY DS!!!!!
STRIVE TO BE THE BEST YOU CAN BE AND DO THE BEST THAT YOU CAN.
Check out www.dsfacts.com and www.duodenalswitch.com for all the accurate information on the great DS, and find surgeons in your area or around the country or out of the country.
I couldn't have done without all the great peeps on this board. 
SW: 234.5 CW: 157 GW: 140 - ish
Karen,
Yes this is the secondary insurance. My primary does not cover anything WLS related. I still paln on fighting. I am still hopeful of proving the Medical Necessity to them for the revision.
Plan B is either $28,000.00 in California or out of the country.
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
