Beverly N.

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02/10/2006 - Well, I finally got all of my pre-op testing completed and faxed into Dr. A last week, and finally today Kathy called and told me ...I HAVE A DATE!!!!! I will be switched on March 28, 2006!!! 

It's so hard to believe that after two years of hoping for this, that in just over 6 weeks, I'm actually going to be on the losing side! I finally called and told my mother - I hadn't even let her know that I had been approved, because it didn't really seem real - not until I had a date! But now that I have a date on the calendar and can start counting down the days, it can all start seeming real, and not just some kind of a dream. 

I guess I better start thinking about what to bring to the hospital and what to have on hand for when I first return home, huh? These next 6 weeks are sure to go very, very quickly! Oh, what a glorious Spring this will be! What a wonderful new beginning for me! 

Thanks be to God, Dr. Anthone, and even the folks at Cigna who finally got it together and approved this thing!

01/11/2006 - I can't believe it! I'VE BEEN APPROVED!!!!! Let me back up and tell you what happened. 

I had called Dr. A's office last Friday to see if they had heard anything yet, and was told that they were still waiting for a response from my PCP. I asked exactly what it was that they needed from her, as we weren't exactly on speaking terms. Apparenly CIGNA had requested something, Dr. A's office didn't know what specifically, on 12/6/2005, from my PCP, and as of 12/20/2005 had still not received a response. 

So I started the follow-up with my doctor. It turns out all record requests are handled through a separate company for my PCP, so I contacted them, and turns out they had never received the request from CIGNA. 

So, here I am again, waiting two months, and nothing has been accomplished. 

So I get the fax number where the request should have gone, and call CIGNA. Of course, you never get to the right person in CIGNA the first time, so first I talk to Gary, who doesn't even know how to handle a surgical pre-determination. Finally he transfers me to Monica who is very helpful and acknowledges that she has my file (73 pages worth!) but that she doesn't know what it is that was requested. For that, I need to speak with Intercorp, the group that actually makes the decision on wheather or not to authorize the surgery. So she gives me the 800# to Intercorp (which, by the way, I have tried unsuccessfully to obtain for over a year!), gives me the image # for my records, and says to reference that number to Intercorp so that they can find my file. So off I go to call Intercorp. 

I am not really hopefully, as the last time I was given a number for Intercorp it was a fax number, but this time a real, live man answers the phone and says his name is Kevin. It turns out that Kevin is actually the person who has been handling my case (my old case, the original RNY surgery request) since the beginning. I can't believe it! Anyway, he's really nice, and very understanding about my frustrations. 

So I ask him where things are at - and it turns out that he says the last thing in my file is the denial of the appeal last November. I explain that I have since opened a new claim with a new surgeon, and he says, nope, don't show anything here. 

So it turns out that even though CIGNA had my paperwork - they had it somewhere that wasn't doing me any good. So what he did was open up a new claim with all of the new information. Then I called Dr. A's office back, and they re-faxed all 73 pages back to Intercorp to the fax number that Kevin gave me on Monday morning, and on Wednesday afternoon I was approved! WHAT A MIRACLE!!!! Amazing what can be done when you finally get the right stuff to the right person! 

Thank you Dr. Anthone, thank you Christy, and thank you Kevin!

12/08/2005 - It has taken me a couple of days to calm down enough after hearing the news about the Medicare decision to drop DS coverage effective February 2006 to even post here. As you may remember, this was supposed to be my Ace in the hole backup plan as I will be eligible for Medicare effective April 2006! Two months too late!!! If this isn't the sad story of my life, I don't know what is!! I still have some slim inkling of hope that Dr. A will be able to perform another of his miracles and get me approved through CIGNA, but I have fought for so long, at this point, it is difficult to keep the faith. I would sure appreciate any and all prayers - I really need your help!

11/22/2005 - My appeal was DENIED by CIGNA again! Even though I thoroughly documented over 29 weeks of physician- supervised diet, I was denied Medical Necessity based on failure to complete 26 weeks of physician-supervied diet! 

My original denial had included four points:  BMI 40 or over for 1 year or more, psychological clearance, physician clearance and 26-week physician-supervised diet.  At this point, the only thing in question is the diet, however, I had thoroughly addressed all of the above in my appeal. 

After I received my letter (and after crying, raving, screaming, weeping, yelling, cursing, etc.) I called CIGNA to question why I was denied since it was clear that I had included sufficient documentation to prove the 26 weeks of physician-supervised diet. After reviewing my file, the CIGNA representative agreed that there appeared to be enough documentation to have been approved, but since it had been sent through the Appeal Unit, my only recourse is to file another Appeal. So I was advised to resend only the documentation applicable to the physician-supervised diet, and go ahead with the 2nd Level Appeal. Although this makes me really nervous, since this is my last level of appeal, I really don't see any other recourse. I am preparing a new letter once again pointing out the pertinent portions of my doctor's letter along with the chart notes from all of my office visits, this time with weights highlighted. I will also add a table of appointment dates, weights, BMI's highlighting total number of weeks of supervised diet. 

If this doesn't work, I guess I'll have to throw myself on the mercy(?) of my employer (since it's a self-funded plan) to see if they have any more common sense than the insurance company does. I just can't afford to sue the bastids!

November 16, 2005 - Well, I went for my consult with Dr. Anthone on November 2nd. He and his staff were just as nice as I was led to believe! My daughter and I came an hour before my scheduled appointment time in order to view the required seminar on video since we were unable to attend the seminar in person, having travelled to Omaha from the Chicago area. (The seminar is only offered once a month.) We also had a TON of paperwork and questionairs to fill out, all of which took MUCH longer than one hour to fill out. I really wish they would have sent the paperwork ahead of time so that I could have had it prepared and brought it with me, instead of having to rush to try and fill it out! 

Anyway, as soon as we were done, they got us right into a room, weighed and measured and photographed, and before we know it, Dr. anthone was there. He was very patient, in spite of us running late, and took the time to answer all of our questions. He also encouraged us to email him personally if we thought of any additional questions later. 

The insurance gal also spent a lot of time with us explaining how she works to get approval. I must say that I am cautiously optomistic that Dr. Anthone's office may be able to "pull a rabbit out of the hat" and actually get CIGNA to approve my DS!!  She did say, however, that it normally takes 6 to 8 weeks to hear anything, so I am trying to be patient! Keep your fingers crossed!

October 31, 2005 - To play it safe, I have decided to appeal my denial for RNY that was originallly dated 5/2/2005, even though I am persuing the DS at this time. The reason that I am doing so is that I still have bills outstanding that will not be paid unless the original procedure is determined "medically necessary". Once it is deemed "medically necessary", then those bills will be paid, and then I don't care about the RNY any further, other than than it establishes "medical necessity" for WLS in general, then it is just a matter us "upgrading" to the DS.

October, 2005 - I have been having a difficult time getting approval with my insurance. It is actually a self-funded plan (Eddie Bauer), administered by Cigna. I was denied for medical necessity on my initial attempt to get the RNY approved, even though my PCP sent in documentation that fully addressed each of the points of the denial letter. It is really frustrating. I have been back and forth with both Cigna and Eddie Bauer for quite a while, and have reached the point that I am just going to drop the efforts to get the original RNY request approved (I was still trying to get this done so that my pre-op expenses would be covered) and go ahead and change horses and go for the DS.

I called today and made my appointment with Dr. Gary Anthone for November 1st. I have until November 9th to file an appeal on the original denial with my insurance company. I talked to Dr. Anthone's office about that, and was assured that they would help me get the appeal sent out within 1-2 days!! 

Please pray that Cigna and Eddie Bauer will look favorably on my appeal and approve me for the Duodenal Switch surgery!

I'll update more after I've met with Dr. Anthone. Until then, Bye!