Denial Letter, AKA Adventures in Asininity (x-post)

True.  Giving up is a sign you aren't ready for this huge life change.  Fight the *******s :)

Sometimes, the U of MN Physicians might not have sent the correct information:  "records sent to us do not meet coverage criteria". 

I would specifically ask for the MD's name that denied the DS.  I would write a letter with the LATEST and GREATEST research about the DS.  That is is the most effective, that it is effective for BMI's like mine starting at 43. 

Sayeed Ikramuddin's office should be able to assist.  Also, since your in MN, why not use the fact, in the appeal that HealthPartners (A HUGE MINNESOTAN HMO) blanket covers the DS in the same manner/criteria that the RNY and Lap Band are also covered. 

:) 

Stay strong, stay focused, it's not over.  Keep fighting.

Kathy

Medically Necessary: 

Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band^® System or the REALIZE^™ Adjustable Gastric Band), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria:

1. BMI of 40 or greater, or BMI of 35 or greater with co-morbid conditions including, but not limited to, life threatening cardio-pulmonary problems (severe sleep apnea, Pickwickian syndrome and obesity related cardiomyopathy), diabetes mellitus, cardiovascular disease or hypertension; AND
2. The patient must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery; AND
3. The physician requesting authorization for the surgery must confirm the following:
   • The patient's psychiatric profile is such that the patient is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and
   • The patient's post-operative expectations have been addressed; and
   • The patient has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and
   • The patient has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and
   • The patient has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and
   • The patient's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and
   • The patient's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed. 

Surgical repair following gastric bypass and gastric restrictive procedures is considered medically necessary when there is documentation of a surgical complication related to the original surgery, such as a fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band herniation, or pouch enlargement due to vomiting.  

It calls it the Biliopancreatic bypass with duodenal switch, but says it is medically necessary with lower BMI's.

Thank  you for that as well!  When I spoke with our union rep earlier today who manages our fund I had even brought up the fact that Empire BC/BS in MN blanket approves the DS across the board with the same prerequisites you listed.  PLUS the other cool thing they had in their list was page after page after page documenting the superiority of this surgery over others in treating MO & esp. when you have the specific comorbs I have (although I've lucked out thus far in not developing the type 2 stuff..)  I spoke to Dr. I's insurance go to gal and she said when he found out I was denied he was livid & can't wait to do the peer to peer & get me overturned!  Plus they were able to up my surgery date to August 27th as our insurance tpa will be changing September 1st & very possibly will no longer cover any type of WLS...  Under the gun, but I'm not going down without a fight!! 

& once again:

YOU ROCK WOMAN!  I hope someday we have the chance to meet!