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  1. #1
    Gastric Sleeve Member
    I have had a gastric sleeve.
    Surgery date
    02/04/2014
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    Dr stoweres
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    Post Need honest opinions on my appeal letter. Please

    I am on my final appeal. This will be my external review. I have been trying to write a personal letter with added documentation. Do I need to try to shorten it to one page? If so what do I take out? Any English teacher here that can help with grammar issues? Lol

    Blue Cross/Blue Shield
    Of Texas
    Appeal Id No 529532425

    To Whom It May Concern:
    I am writing to you to respectfully request an IER (Individual Eligibility Review) and for my case to be reconsidered.
    This surgery I am requesting is not cosmetic. It is reconstructive following a massive weight loss per American Society of Plastic Surgeons and the American Medical Association. Like breast cancer is a disease and reconstructive surgery is covered in the state of Oklahoma where I reside. I had the disease of obesity. Which has left my skin very abnormal. I do not have a normal life or appearance due to the massive amount of skin. It is unhealthy, unsanitary, and is a hindrance to my health and well-being.
    After several years of trying to get approved with your insurance company for Gastric Surgery I was finally approved in 2014.
    I am 5’7 and weighed over 300lbs. I had a BMI of 52 which put me in the Super Morbidly Obese category. I have enclosed a before picture which you can see that the majority of my fat was in my abdominal and hip level, thus leaving me with a massive amount of extra flesh and skin. Above and below my belly button. I currently weigh 157lbs.
    Due to the excessive amount of skin, I suffer from severe anxiety, poor body image, depression, skin-eruptions, skin breakdowns, itchy rashes, oozing sores, and chronic back pain. I also have problems with daily living activities and ambulation in exercise and sexual activity due to my massive pannus.
    Unfortunately during my rapid weight loss, having destroyed the elasticity of my skin with morbid obesity, I have been left with a mass of skin hanging from hip to hip and below my pubis.
    The reason I am requesting this abdominal or panniculectomy surgery is to be able to move without constant pain from the tugging and pulling on my back and the constant skin irritations and unhygienic conditions caused by the overlapping and chafing skin.
    I now suffer from chronic rashes between the layers of skin at my waist and under my pannus, they are painful and unhygienic. There is nothing normal or hygienic about my skin. I have also included documents from my dermatologist and primary care physician where I have been seen for my skin problems.
    One of the Medical requirements is that my skin hang below my pubis which mine does. I have to lift my skin in normal daily activities, like washing. I take 2 showers a day to try and keep my skin clean. I then use a hairdryer on cool air setting to dry my skin before using the Nystatin powder prescribed to me by my PCP to keep infection down. I also self-medicate with triple antibiotic ointment, Aquaphor ointment and powders with cornstarch, to no avail. My PCP Has suggested these products with little to no success. My skin folds rub together and always are several red and irritated. There is always a horrible embarrassing odor that I try to cover up the deodorant and sprays over the top of the skin. None of this is normal hygienic care. These are some of the extreme measure I take every day, just to try and keep the rashes under control. I carry baby powder, wipes, and ointment in my purse. To use on lunch breaks. Normal people do not have to do this. With summer coming the out breaks will increase to oozing crusty sores. Due to the heat and rubbing. There is no way to keep the skin up and dry. I have to pick it up and tuck it inside my underwear. I wear moderate to firm control underwear to try and help alleviate my back pain from it pulling and hanging. It does not work.
    This is humiliating and embarrassing to even talk about this, but it has given me a whole new set of body image issues including anxiety and depression which has intern put a lot of stress on my marriage. The hanging pannus has caused serious ambulation issues in sexual relations area, physical and psychological. I have to hold my pannus up to provide sexual intercourse. It flops over my vagina. It hangs and makes slapping noises. I love my husband dearly but can’t stand the thought of holding up my skin, hearing the noises, or even see the amount of flopping, sagging, infected, smelly, and over all disgusting skin.
    I still wear baggy clothes to hide the extra amounts of skin and are very apprehensive of people seeing me. This does not work well working for the public. I tell myself daily that there is a counter so people will not see the extra amounts of skin around my stomach. After all this hard work I have put in to making myself a normal healthy individual. I still am not. For just one day I long to see what it is like to be normal. To not spend extra time in the shower and bathroom moving, picking up, cleaning, and medicating this mass of skin I am left with.
    The mass of skin has also left me with back and leg strain. I am in now in constant pain in my lower back from the pulling sagging skin. I have to compensate for my skin when I walk and thus puts extra stress on my lower back and legs. I am on my feet all day. So most likely I will have more medical issues with my back due to the extra skin. I also try to exercise but it is uncomfortable and difficult with the skin in the way and pulling and tugging on my back. I cannot jog very long due to the pulling and slapping against my legs. If the skin was removed I could exercise like a normal induvial and not be hurt or bothered by the amount of pannus getting in the way.
    Please look into my case with a new sense of urgency to the health problems I have as a direct result of my massive weight loss and massive amount of pannus skin. I have enclosed extra medical documentation as said for my denial reason. I have PCP records, dermatologist, psychologist records, and more pictures showing before and after pictures, and some legion pictures.

    Respectfully,


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  3. #2
    Gastric Sleeve Member Melissa888's Avatar
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    03/15/2016
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    Default Re: Need honest opinions on my appeal letter. Please

    Shorten this letter. The insurances appeals review will not want to read something this long. Include any and all medical documents and make your case as straight forward and concise as possible. God luck to you!



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  5. #3
    Gastric Sleeve Member KariVSG's Avatar
    I have had a gastric sleeve.
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    Kari
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    Dr. Kaplan
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    Default Re: Need honest opinions on my appeal letter. Please

    I agree with Melissa888 be blunt and to the point....



  6. #4
    sraebaer
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    Default Re: Need honest opinions on my appeal letter. Please

    I agree, I see something that long and ignore it. Maybe bullet points of your health issues? Or at least paragraphs? Good luck!

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  8. #5
    Gastric Sleeve Member
    I have had a gastric sleeve.
    Surgery date
    02/04/2014
    Surgeon
    Dr stoweres
    Join Date
    Jun 2016
    Last Activity
    08-25-2016 08:14 AM
    Location
    Oklahoma
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    Default Re: Need honest opinions on my appeal letter. Please

    Thanks guys. It is in paragraphs but for some reason when I copied and pasted it it smoshed everything together lol. It is two pages right now. It is a beating trying to say the right thing. I always hated trying to write a report/professional letter. Now I am writing the most important one of my life at this moment.


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  10. #6
    Gastric Sleeve Member
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    08/16/2016
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    Default Re: Need honest opinions on my appeal letter. Please

    Yes agree way too long and emotional

    If you can ask someone you can trust to help/write it for you.
    Nurses I feel can be to the point w/facts
    I am also a person who adds too much to any note or email, can relate
    Don't ever give up.



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  12. #7
    Gastric Sleeve Member stacydev's Avatar
    I have had a gastric sleeve.
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    Stacy Devenney
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    Dr. Tuggle
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    Default Re: Need honest opinions on my appeal letter. Please

    I don't have any words of wisdom for your letter, but it made me cry. I'm so sorry you have to deal with this on a daily basis. I hope the insurance company takes this last appeal and really considers how the extra skin has and does impact your daily life. Good luck!



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  14. #8
    Gastric Sleeve Member Pam G's Avatar
    I have had a gastric sleeve.
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    Pam
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    05/27/2016
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    Dr Ponce de Leon
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    Default Re: Need honest opinions on my appeal letter. Please

    1. Has your doctor provided medical records documenting the rashes? You need that documentation from your doctor...they won't take your word for it.

    2. Request a phone call between BCBS's medical director and your doctor. It's unusual for the med director to say no directly to the doc requesting the procedure.




    HW: 275
    PreOp: 268 5/12/16

    SW: 258. 5/27/2016
    10 w: 225. Goal 1
    12 w: 222.
    14 w: 216.
    4 m: 215
    5 m: 205
    22: 199.4 10/30 Goal 2
    24: 196
    6 mo: 191
    7 m: 193
    8 m: 184
    9 m: 180 2/3/17. Goal 3
    10 m: 179
    11 m: 171
    48: 170
    1 yr: 166.6. 5/27/17
    13 m: 165.8
    5 y,10 m: 215
    7 yrs: 230


    Revised Goal : 200
    "Bonus" Goal: 180

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  16. #9
    Gastric Sleeve Member Pam G's Avatar
    I have had a gastric sleeve.
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    Pam
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    05/27/2016
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    Dr Ponce de Leon
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    Default Re: Need honest opinions on my appeal letter. Please

    Quote Originally Posted by Pam G View Post
    1. Has your doctor provided medical records documenting the rashes? You need that documentation from your doctor...they won't take your word for it.

    2. Request a phone call between BCBS's medical director and your doctor. It's unusual for the med director to say no directly to the doc requesting the procedure.
    Ok, I stopped reading right before where you said you're including medical documentation.

    I was a preauthorization nurse for UHC and processed several of these types of surgeries. They almost always were denied, but sometimes, they got approved. The main thing is the medical documentation and pictures. And one of the best tactics is having your doctor speak directly to the medical director....your doc has to call and request the call, then the med dir will call your doc back. It's much more difficult to say no to someone directly.

    Do not send your letter by itself, send it along with your doctor's written appeal, med documentation and photos.




    HW: 275
    PreOp: 268 5/12/16

    SW: 258. 5/27/2016
    10 w: 225. Goal 1
    12 w: 222.
    14 w: 216.
    4 m: 215
    5 m: 205
    22: 199.4 10/30 Goal 2
    24: 196
    6 mo: 191
    7 m: 193
    8 m: 184
    9 m: 180 2/3/17. Goal 3
    10 m: 179
    11 m: 171
    48: 170
    1 yr: 166.6. 5/27/17
    13 m: 165.8
    5 y,10 m: 215
    7 yrs: 230


    Revised Goal : 200
    "Bonus" Goal: 180

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  18. #10
    Gastric Sleeve Member
    I have had a gastric sleeve.
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    01/13/2016
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    Dr Gmora
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    Default Re: Need honest opinions on my appeal letter. Please

    Can't help with the appeal because Ontario is totally different. I wrote to mention that several of your sentences aren't sentences. You have phrases instead. A sentence must have a subject and a verb. Ex "which has left my skin very abnormal" should read "the weight loss from surgery has left me with very abnormal skin." I second the idea of using bulletin points, if you organize them carefully it will make your argument more coherent. Good Luck.



  19. #11
    Gastric Sleeve Member Pam G's Avatar
    I have had a gastric sleeve.
    Name
    Pam
    Surgery date
    05/27/2016
    Surgeon
    Dr Ponce de Leon
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    Feb 2016
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    02-22-2024 08:48 AM
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    Default Re: Need honest opinions on my appeal letter. Please

    Quote Originally Posted by Theresa2 View Post
    Can't help with the appeal because Ontario is totally different. I wrote to mention that several of your sentences aren't sentences. You have phrases instead. A sentence must have a subject and a verb. Ex "which has left my skin very abnormal" should read "the weight loss from surgery has left me with very abnormal skin." I second the idea of using bulletin points, if you organize them carefully it will make your argument more coherent. Good Luck.
    There are a few misspelled words, too, but the insurance company won't care about grammar. They focus on what the doctor has to offer. Sure, a personal letter might help sway the medical director's decision a bit, but the main thing is: does the case meet the pre established criteria for whatever procedure is being requested?

    Every ins company uses a set of pre determined criteria for every procedure or medical device being requested. It's a very cut and dried process: either you meet the criteria (approved), or you don't (denied).

    Some things are automatically denied as "cosmetic", such as removal of excess skin post WLS, without anyone even checking to see if the criteria have been met. Most people won't appeal, and the ins co saved themselves a butt ton of money.

    You're doing good by appealing, but remember, you've got to get your doctor to talk to the ins company's medical director that is handling your case (there are several med directors, speak to the one that denied your original request).




    HW: 275
    PreOp: 268 5/12/16

    SW: 258. 5/27/2016
    10 w: 225. Goal 1
    12 w: 222.
    14 w: 216.
    4 m: 215
    5 m: 205
    22: 199.4 10/30 Goal 2
    24: 196
    6 mo: 191
    7 m: 193
    8 m: 184
    9 m: 180 2/3/17. Goal 3
    10 m: 179
    11 m: 171
    48: 170
    1 yr: 166.6. 5/27/17
    13 m: 165.8
    5 y,10 m: 215
    7 yrs: 230


    Revised Goal : 200
    "Bonus" Goal: 180

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  21. #12
    Gastric Sleeve Member JanPit's Avatar
    I have had a gastric sleeve.
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    Janice
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    Default Re: Need honest opinions on my appeal letter. Please

    Hi Pam, I am glad I read this thread. I have been denied twice and did have lots of documentation from my Surgeon, Plastic and Reconstructive surgeon (sho is accredited) and my primary care physician who did write a personal letter of medical necessity. I had scripts enclosed, pictures and a personal letter. I still got denied. I have my annual check up soon and will speak to her about calling the medical director who denied my claim. Thank you!!



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  23. #13
    Gastric Sleeve Member AnnieG's Avatar
    I have had a gastric sleeve.
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    Annie
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    Default Re: Need honest opinions on my appeal letter. Please

    Critical writing means first paragraph carries most intense idea.

    Shorten to one page, try removing emotions and bullet medical criterion met for surgery.

    That said, I m so sorry you're dealing with all this. It's hard to understand why it's denied. I'll be praying for you to be approved. Best to you.
    [I]HW: 240 lbs SW: 199 lbs GW: 140 lbs

    1 MO = 167.0 2 MO = 156.4 3 MO = 148.4 4 MO = 140.6
    5 M) = 136.0 6 MO = 130.0
    1 YR = 122.0 2 YR = 140.00 2.5 YR = 139
    Happy with my weight; happy with my size; over-the-moon with my health!

  24. #14
    sraebaer
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    Default Re: Need honest opinions on my appeal letter. Please

    I think Blue Cross/Blue Shield's policy is to deny no matter what. I fought an ambulance bill of $1,200. I have an HMO for my city, got hurt in my own home, but only an "uncovered" ambulance service serves my neighborhood. I wrote and wrote, and they denied and denied. I finally gave up and paid it.

    Hope you have better luck than I did!

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