Catina W.
I requested medical coverage for Roux-en-Y gastric bypass surgery in February 2008. I thought it was a sure thing. The doctors would explain everything and the insurance wouldn’t be able to deny me. If fact, they would wonder how I have survived so long. The sympathy that they would feel would run deep. My life was about to change. Boy am I naïve.
When my insurance company (BCBS-Fed) denied my claim, I was devastated. I just decided that hey, I will live like this. That mentality lasted for about 4 months. After 4 mos I picked myself up, gave myself a pep talk, and then got angry. Angry first at myself for waiting so long, you have to appeal any denial within 6 mos and angry with the insurance company for questioning my health and medical necessity, who do they think they are?So there I stand, angry.
I wrote the appeal letter. The process helped me heal. I had to make sure that the people reviewing my case understood the necessity for my surgery. Maybe the doctors did not send a clear picture of how my co-morbidities effected my ability to lead a normal and fullfilling life. Maybe the doctors didn’t explain the pain that I was in everyday. Maybe the doctors didn’t meantion all the medications that I took or the side effects of them on me. Maybe the doctors weren’t clear enough, or precise enough, or maybe they didn’t explain that hey, this woman needs this and you are denying her the right to a full and just life. Maybe the doctors weren’t the ones that needed to be shouting for me, so I found my own voice.
In the process I learned that if you want something you need to work for it. It took me several weeks to acquire all the medical documents that needed to be sent. I had to visit every doctor that I believed would add credibility to my medical necessity appeal. I researched other case studies similar to mine and utilized the information that I found in order to help me write my case. When all was said and done I sat there with almost 40 pages of reasons that I needed this. I dropped the package off to the insurance coordinator at my surgeon’s office and waited.
Nothing wonderful ever happened because someone sat on their butt and waited for action. A week later, I called my insurance company and they confirmed the receipt of my appeal package. Ok good no worries. Should have my answer in three more weeks. I start checking my mailbox everyday with the anticipation of a child watching a cookie bake. My answer did not come. I called on day 30, they ordinarily have 30 days to respond in writing to an appeal. The representative stated that the information was not with the correct appeal group, being that I was appealing a pre-certification and that she would take care of making sure the information was received by the right people. What? So I waited. After several days I called the insurance company again, I really did not believe in this sort of run around and wanted some serious answers. This time it seems that my appeal package had been lost. The representative calmly explained that I would need to resubmit my appeal package and she gave my a contact person and a fax number. I sure am glad one of us was calm.
Now I am ordinarily a very organized person, ordinarily. But I think with all the hubbub and ado I lost my copy of the appeal package. During this time my computer, my lifeline and now my mortal enemy, had crashed and I lost all the information. Forty pages of work, of my life stored on a little burnt out device the size of a credit card. Once the shock wore off I started to think, I had one chance. If the insurance coordinator saved a copy of my appeal, then I might still be in this. I called, she answered. What an Angel, a ray of light in a dark world, had she been standing in front of me I may have just kissed her. She made me a copy. All is good with the world.
Suddenly I started receiving correspondence from the insurance company. They needed more information from this doctor or about this condition. I finally felt that I was getting somewhere or it was a great dog and pony show. Either way progress marches on. After several more weeks, I received the coveted letter that I had waited for, the DECISION. I stood by my mailbox and just stared. This was the moment of truth. I went inside sat down and opened the letter. Dear Ms. Wolfe we would like to inform you that your request for pre-certification for RNY gastric bypass surgery that had previously been denied has been approved. I sat silent. Then I yelled real loud.
A year ago, I would not have believed that I would make it to this point. I am currently one week post-op RNY and feeling for the first time that I may have options. I begin my journey again at 36.
About Me
Cary, NC
Location
23.2
BMI
Surgery
02/13/2009
Surgery Date
Feb 01, 2009
Member Since
