lessthanB4
So many people write to me wanting to know how I "beat" Blue Cross and what I enclosed with my appeal letter so here are the details. It's long but if this helps even just one person it was worth it! Most of all, I encourage everyone to exhaust all manners of appeals. I know sometimes it's easier to just give up but, keep in mind that nothing worth having comes easy. I think I appreciate my band so much because I had to fight for it! If I can win so can you!
(If you were denied due to a specific WLS exclusion from your plan, it may be close to impossible to get it approved. The only suggestion I have is: if your coverage is through an employer, get with the human resources department to see if your plan is self-funded. If your plan IS self-funded the employer may be willing to make an exception to allow you to have the surgery.)
Have you received your denial letter? If so, what is the exact reason that your request was denied? I guess in a way I was kind of lucky since Blue Cross only denied me because they consider the LapBand experimental/investigational (in other words, I was not denied due to not having a physician supervised diet etc.). So, the only thing I had to prove was that the LapBand is NOT experimental/investigational.
Also, my plan offered 3 levels of appeal which were outlined in the initial denial letter from BCBS. 1. a written appeal that I was to provide to them as a plea to re-evaluate my claim 2. a conference call with the medical review board to verbally state the facts that support LapBand surgery 3. an external review board (in that order). My letter also stated that if, at any time, BCBS did not respond to my appeal request within 15 days I had the right to skip any further in-house appeals and request an immediate review by an external review board (which is what happend). I did not receive a written denial from my first appeal until 21 days after BCBS had received it. At that time, I requested that my appeal be handed over to the external review board. At this point, I knew I had them in a bind because they, at first, refused to skip the second level appeal. I threatened to hire an attorney because I had written notification from them that it was my RIGHT to go directly to the external review board. Because they showed hesitation in doing this, I felt I had a really good chance once a third party stepped in. I also contacted the State Board of Insurance and was told that legally they only have 15 days to respond or they are in default. So... KEEP A SHARP EYE OUT FOR ANY LOOP HOLES THAT YOU MIGHT FIND TO USE TO YOUR ADVANTAGE.
I wish I could send you EVERYTHING that I included with my packet but I think it's something like 164 pages! I really think that I provided them with more information that supported the band than what they could find against it. I have comprised a list of my enclosures. Most of which I printed off of the web. I wish I would have kept URL's for this information but I didn't. Maybe, at least having the names will help you in searching through search engines.
One thing that I think really benefited me was that I put everything together in a nice, professional type binder and used labled tab dividers between each document. Blue Cross and the rep. at the external review board both commented on how impressed they were with the "presentation" of my appeal. I made sure every document was labled and referred to in my appeal letter so that it was easily referenced by my reviewer. Also, the last page of my appeal letter was a list of my enclosures and a quote or statement listed under each title of the most important points that I wanted the reviewer to get out of that paticular document or the statements that most supported my appeal. Here is an example of what I'm talking about:
Enclosure [4] FDA, The Lap-Band Adjustable Gastric Banding System
Summary of Safety and Effectiveness Data
**Page 24, numbers XII, Panel Recommendation and XIII,
CDRH Decision show that the Center for Devices and Radiological
Health (CDRH) required 3 years follow-up prior to approval and
that this requirement was met.**
Ultimately, I think the enclosure that convinced them that the LapBand is not investigational was the Letter to BioEnterics Corp. (Inamed) from Department of Health and Human Services, June 5, 2001. This is the only document that was referred to in my approval letter from the external review board.
Also, on my physician's website it lists his credentials so I printed it out and included it with my packet. Let them know, in your appeal letter, that you not only have researched every WLS but that you have researched your surgeon and have concluded that he/she is more than experienced and knowledgeable in performing this type of surgery.
I hope that all of this information is not overwelming to you. If you have any questions about anything I have touched on or need additional information please let me know.
Here is a list of my enclosures.
Press Release, May 3, 2004 (LapBand System Approved for Plan Reimbursement of
Blue Cross/Blue Shields of Texas, Illinois and New Mexico) I believe you can find this information on Inamed's website. Even though the BCBS I am covered under is in PA, I included this document to make the point that how can some BCBS in some states cover it and other not?
Letter from Dr. Vicki Schnell, MD
This is a letter from my infertility doctor supporting my decision to have LapBand surgery and listing my medical problems.
WebMD Health, Medical News Article, June 5, 2001
FDA Approves Implanted Stomach Band to Fight Obesity
Letter to BioEnterics Corp. (Inamed) from Department of Health and Human Services, June 5, 2001 You may be able to find this or information like this by doing a search for Department of Health and Human Services and then searching their website for keyword: Laproscopic Adjustable Gastric Band
Long-Term Results of Laparoscopic Adjustable Gastric Banding for the Treatment of Morbid Obesity, M. Belchew, MD
Laparoscopic Adjustable Gastric Banding at a U.S. Center with up to 3-year Follow-up, Richard B. Rubenstein, MD
Citation from the publications of Christine J. Ren
Entrez PubMed, Complications after laparoscopic adjustable gastric banding for morbid obesity: experience with 1,000 patients over 7 years I felt that it was important to include a little information on the complications, not only to support that the LapBand is less invasive and less risky but, to show that I had really done my research and I was fully aware of the complications and that I knew that my being overweight could cause far more health problems than the band.
News Release, WISH Center
FDA, The LapBand Adjustable Gastric Banding System Summary of Safety and Effectiveness Data
Spotlight Health, The LapBand System Overview
Procedures, Results, Surgical Risks, Recovery
Press Release, June 5, 2001, FDA Approves PMA for LapBand Adjustable Gastric Banding System for the Treatment of Severe Obesity
Press Release, January 6, 2003, Special Supplement to American Journal of Surgery of LapBand System Published
Information on Dr. Felix Spiegel, MD This was the information that I printed out about my surgeon.
Please keep in contact with me and let me know how everything goes and good luck in your journey towards WLS.
Lisa
9/17/04
I am 34 years old and married to the greatest man in the world. I have been over weight my entire life but have "put on" about 80 pounds since my husband and I married. We are celebrating our 10th anniversary this year and I am so ashamed of myself. I feel so bad for him, he wanted to take me to Hawaii but I won't go because of the way I look. We have no children (I have PCOS). He has suffered through infertility treatment with me and I am even more ashamed of myself when my infertility doctor tells me in order for the treatment to work I must lose weight. It's just not fair to him (or me) but he loves me anyway. I have absolutely no control over my eating and no drive to exercise. He has been 100% supportive of my decision to have WLS. Just making the decision to have the surgery has given me a new outlook on life. I even plan on taking him up on the Hawaii trip 6 months post-op! I completed my initial consultation with Dr. Spiegel today. He is so nice. He explained the procedure to me in detail and even showed me the actual band. His office will file the necessary paperwork with BCBS to get approval.
Spoke to BCBS, they state they have not received anything for pre-cert from Dr. Spiegel's office so I initiated the pre-cert. myself. Procedure code given to me by Dr's office (43659) was given. The nurse handling my case is Donna Applegate.
4/27/04
Was notified by Elsie Ramos in pre-cert department that procedure is considered "experimental/investigational" and is being denied. She gave me the appeals # 888-671-5276.
4/28/04
I initiated my level one appeal. Raylene Harberger is my appeals specialist. I have faxed info to her supporting that the lap-band has been approved by the FDA (2001).
4/30/04
Visited my PCP today. He does not understand why BCBS is considering lap-band experimental. He states the surgery has been done for years. He will contact them directly. I provided him with Raylene's phone number.
5/4/04
Contacted Inamed for assistance in proving the lap-band is not experimental. Lisa Maddock e-mailed me information from a press release from May 3 stating that BCBS of Texas, Illinois and New Mexico will now provide coverage for the lap-band.
Passed Inamed info on to Raylene. Per her supervisor, since my benefits are through BCBS Pennsylvania this does not apply to me (even though I live in Texas).
5/11/04
Visited Dr. Speigel again today. He says for me to be persistant with the insurance company. His office will submit request for pre-cert for removal of gall bladder at same time of banding.
5/20/04
Visited PCP again, he states he attempted to contact Raylene twice and left voice mails but she never returned his call. PCP agrees to have gall bladder removed during surgery.
5/21/04
Per Donna in pre-cert at BCBS, she approved the removal of my gall bladder for May 24th. What good does it do me if they haven't approved the band?!?! Will have to call her back with new surgery date and get re-approval.
5/24/04
I received my "official" first level appeal denial letter on Sat. I took time to read the entire letter and found I may be able to "skip" the second level appeal and go directly to the external appeal process. I filed my appeal with BCBS on April 28th. They have a 15 calendar day policy that states a decision will be made within 15 calendar days or you can excercise your right to an external review board. The denial letter was dated May 18th (20 days after their decision time frame). I faxed a letter to the appeals department notifying them that I want to go with the external review board. They have 5 days to respond, in writing, to receipt of my request.
5/25/04 2:13 pm
Received call from Raylene Heyberger today. She states she received my letter and that she got with her supervisors and they told her that it HAS to go through the second level appeal. I showed her where, word for word, in thier letter to me it states I can request an external reveiw board. She asked me why I thought that would benefit me. I told her time wise for one (15 days for 2nd level, then another 30 days for external). She said in her opinion she thought I should take advantage of the 2nd level appeal. I asked her how she thought that would benefit me (she just said she had seen stranger things happen). I told her that if I was denied my right to an external appeal at this time I was going to hire an attorney. I also told her that I may need to hire one to handle this anyway. She told me she would love to see me get an attorney and have this decision overturned that it would help so many people out there. WHATEVER!! She is checking with her supervisors again to point out what their letter says. She will call me back.
5/25/04 2:58 pm
I can't believe I let BCBS upset me so bad. I have to keep reminding myself that this is a journey, one step at a time. Still, they can not convince me they are doing anything for MY benefit. If they were, they would have approved me by now.
5/26/04 3:23 pm
Called Raylene, apologized for getting so upset yesterday. She said she understood my frustration. She checked with her supervisor and my file is going to the 3rd level appeal (the external appeal process). She stated someone will be contacting me shortly.
6/1/04
Received a certified mail notice in mailbox. Must pick up at post office because it has to be signed for. Notice states letter is from Blue Cross. Will pick up tomorrow.
6/2/04
Called post office and spoke to "Guidry" she has the letter there and will not let the carrier bring it back out on her route today. Advised her I will pick it up from the post office.
6/2/04
Letter is confirming my request to go straigt to the External Appeal and gives me my contact person at BCBS and the contact person at HealthQuest (the external review board).
6/3/04
Spoke to Sandra @ BCBS, she states for me to overnight my package to her and she will include it with my file to be sent to HealthQuest on June 9. Sent package today with letter. She stated it usually doesn't take the full 30 days and that a decision is usually made within a couple of weeks.
6/07/04
Stacy with Personal Choice called me today. She states they received my package and will be making a copy to send to HealthQuest. I freaked out. I told her that I specifically put the presentation together for HealthQuest not BCBS! (I spent $12 on binder and tabs, not including copies). She assured me that she would see to it that HealthQuest got my packet just as I sent it to BCBS. I will check with HealthQuest on Friday.
6/11/04
Talked to HealthQuest. They did receive my package and original binder etc. that I sent BCBS was in with it. It has now been fowarded to the reviewing physician.
6/28/04
I called HealthQuest and they stated a decision has been sent to BCBS and referred me to them. Per Donna @ BCBS .... THE DECISION HAS BEEN OVERTURNED (OMG) I am shocked! They sent my approval letter out on June 24th. I called hubby and he is so excited! He said to set-up the date and time and he'll take vacation days. I called Mom and she almost started crying. She is so happy for me. I called Dr. Spiegels office and left a message for Melissa need to do pre-op and set a date!!
6/30/04
I HAVE A DATE! July 7, 2004! Because I am not over 250lbs I'm not required to do the pre-op liquid diet! Yipee!
7/01/04
Met with Johanna today at surgeon's office. She went over pre and post-op stuff with me. Went to Doctor's Hospital in Groves and had bloodwork, EKG and chest x-rays done. Everyone at the hospital were so nice. I really feel at peace. My mother spent the day with me doing all this running around. I'm so glad she did, I really enjoyed her company. We laughed and giggled so much. It felt really good.
7/9/04
I feel wonderful! I can't believe I'm two days post-op. Each day has gotten better and better. My incisions are a little stingy and I'm a little sore but other than that I'm amazed at how "normal" I feel. I have had very little gas pain and have been up walking around since a few hours after surgery. Everyone at the hospital were so nice, I was really impressed. Overall, this has been a great experience.
7/13/04
I am one month and six days post-op and I feel "normal". I have lost 14lbs, (9lbs post-op). My weightloss has been slow and has almost come to a complete stop. The words of all my good bandster buddies keep ringing in my head "the first six weeks are for healing, not weightloss". I am scheduled for my first fill on Aug. 23 at 3:00 so I hope this will make a difference. I, of course, have experimented with all types of food and find I do not have a problem with anything. The only thing I have not tried is rice. I have suprised myself by excercising on a regular basis. I started the Walk Away the Pounds tapes and have worked up to the three mile tape! I attended my first (Dr. Spiegel's second) support group. They only have them once a month but I get lots of support from my fellow band forum members. I got my staples out on July 14 (I had 16 staples and 5 incisions). By accident, I felt my port for the first time on Aug. 11th. I haven't felt for it before because I thought it would freak me out but it's really kind of cool.
9/03/04
I can't believe it's been so long since I have updated my profile. I had my first fill on Aug. 23 and I didn't feel a thing! I have a small amount of restriction but I'm not really satisfied with it. I did not lose any weight in Aug. but the month was a real experience for me. I finally realized that I have to eat SOLID food, not things that will slip through my band easliy. I was so afraid that I would hurt myself that I kind of kept myself in the mushy stage without even realizing it. Since my fill, and since eating solid protein, I have noticed the inches dropping off. My scale is still not moving much (down 2 pounds) but, I can feel the difference in my clothes. I have been very committed to excercising and have been riding my bicycle 3.5 to 4 miles a few times a week. I have attended two support group meetings and really enjoy conversing with other bandsters. I learned from the meeting that if I am at my sweet spot I will only be able to eat approx. 1/2 cup of food and feel stuffed! Overall, I am so happy I did this. I have so much more energy and I wake up so much easier in the mornings. I'm not tired all of the time. I LOVE MY BAND!
9/14/04
I had my second fill today. Dr. Spiegel filled me to 1.8cc. I hope that it helps. I have been really disappointed in my weight loss. He told me not to excercise as much as I have been to ONLY walk. He does not want me building muscle and not losing weight!?! He said I should not be able to eat a whole chicken breast so I guess I'll see how much restriction I have when I can start on solid foods again. I tried to tell him what I was eating but he stopped me and told me he didnt' care WHAT I was eating but HOW MUCH I am eating. He says the limited quantity of food is what will cause me to lose the weight. I'm so confused! I thought I was doing good by watching what I eat and excercising.... now he's telling me something different. Thank God I have my band to keep me straight because Dr. Spiegel keeps me confused. I talked to him about my siatic nerve pain and he told me that one anti-inflammatory injection probably wouldn't hurt anything but I can not take anti-inflammatory pills on a daily basis. He said as long as I am carrying this extra weight my back will continue to give me problems.
10/14/04
I had my third fill on Oct. 5 and I think this is finally "the one". I can no longer eat large amounts of food and it is more difficult to get chicken and bread down. I have started losing again. I also have began bringing my lunch to work as it seems ridiculous to try to eat out (I also fear that I will PB in front my co-worker that I eat lunch with every day, she doesn't know I had the surgery). I have more control over my food and how much I put in my mouth and have more time to chew if I eat at the office (I always feel rushed otherwise). I am doing good at exercising by doing my 2 mile Walk Away the Pounds tape three days a week. I am now down to 215!
11/22/04
I am so excited .... as of Sunday I am down to 211 ... I teatered between 212 and 213 for almost a month and then FINALLY, I got below 212! I am definately eating alot less than I was even in Oct. I feel like maybe my third fill finally kind-of "kicked in" after almost a month (kind of strange, I know but I've heard that things like this do happen with the band). I've slacked off on my excersise since the time change and am working towards getting motivated again. The strange thing about all of this is that I do not feel deprived of anything, like being on a "diet" and I'm still losing weight!
4/16/05
Wow! Where has the time gone? It has been 5 months since I last updated! I have had two un-fills and several fills since my last update. I am down 34lbs. and weigh 202 as of today. This is the least I have weighed since surgery. My weight loss has been EXTREMELY slow (too slow really) but, it's coming off. I fluctuated between 203 and 205 for two months, had a fill on Tuesday, and have finally made it below the 203 mark. Now I'm shooting for below 200!!! In January I signed up for a six week "Boot Camp" at my local gym and, to my shock and suprise, I completed the entire three days a week for six weeks program! I lost absolutely NO weight but I toned up a ton! Towards the end of the class my friends, family and co-workers kept telling me how they could tell I had started losing weight again - but, I never lost a pound the whole six weeks. I did gain a TON of self confidence though. I can't believe how much I enjoy going to the gym. Pre-band I would not have stepped foot in one for fear of critisism, not to mention my laziness. But, my band has given me a new lease on life and I'm enjoying every minute of it. There are alot of days, especially when I am browsing this site, that I can't believe this is all real. Sometimes I can't believe that I actually went through with this life changing surgery and how blessed I am to have received this priceless gift. I would do it again in a heartbeat.
