I can't do it.....
I just don't think I can do this. I am feeling totally defeated. My case has been closed at the medical group, two referral requests (instead of a request and then a resubmittal of new info....becuz of RETARD PCP office!!!!!!) BOTH denied for the same reason.....lack of medically supervised diet.....you can't have 2 denials for the same reason SO my case is CLOSED. CLOSED. I am back at the Health Plan dealing with them and I now have to file a formal appeal WHICH I was advised to handle myself since the PCP office ihas there heads up thier bottoms. Like with 4 kids (three 4 and under), Christmas and a business I haven't got enough to do. I just don't know if I can pull from anymore sources, I am flat tapped out........
............lie to me, fill my mind with sweet little lies that might give me false hope and strength.........
Here is what I will be submitting to the insurance (rough draft), a formal letter and my personal letter along with the Dr's information.
FORMAL LETTER
Mrs. Brittany Phillips
**** Grand Ave
San Diego CA
(***) *** ****
November 29, 2004
Attn: Appeals and Grievance Unit Sharp Health Plan
University Avenue, Ste 200
San Diego a 92105 FAX (619) 288 2447
Dear Director of Claims
Sharp Community Medial Group recently denied a request provided by Dr. Schoengold for a referral to see Dr. Kyle Potts M.D. Inc. The referral was for a bariatric surgery consultation and was denied originally on Oct 11, 2004.
Denial of this claim was determined by the lack of established medical necessity criteria or guidelines, specifically that I did not have a medically supervised weight loss program for a 6 month period within the last 3 years. This finding is not justified and I am appealing the denial. Please be aware that I have completed numerous medically supervised weight loss programs for periods of 6 months or more over the last 15 years. (Please see attached diet history) One of which being a 6-month period from February 2004 to September 2004 during which I lost approximately 25 lbs and was supervised monthly by Dr. Schoengold’s physian’s assistant and nurse practitioner.
Please furnish the name and credentials of the insurance representative who reviewed this claim. Also, please provide an outline of the specific records reviewed and a description of any records that would be necessary in order to approve the claim.
Also, please furnish copies of any expert opinions that have been secured by your company regarding this matter so that Dr. Schoengold may respond to its applicability to this request for referral.
Please review this claim again. The information is correct and reflects the appropriate required information. If you need further information, please inform me so I can get you the information you need to expedite the approval of this request.
I can be reached at the following telephone number(s):
Home: (***) *** ****
Cell: (***) *** ****
Thank you for your prompt attention to this matter.
PERSONAL LETTER
To Whom it May Concern,
I would like to take this opportunity to explain the circumstances I believe lead to the denial of the request for a bariatric surgery consult referral to Dr. Potts submitted on my behalf by Dr. Schoengold.
After the initial referral request was submitted (approx 10-06-04) I was in contact with the Sharp Community Medical Group (SCMG) almost daily to find out the status of the request. I was informed during a phone call on the 11th of October that I had been denied and for what reasons. I received the notice of denial of medical coverage on October 12, 2004. I was given information by a pleasant and extremely helpful customer service rep at SCMG who told me of the option to resubmit new information showing I did met the requirements of having a medically supervised six month diet in the last 3 years on October 13, 2004. I saw Dr. Schoengold’s NP, Maureen Flemming, on Thursday the 14th of October and we went over my medical records. She found, in my medical records weight loss of approximately 20 lbs during the time I was on the Weight Watchers online program. I followed their “points” plan for a little over 6 months on the advice of Kay Bradshaw, another of Dr. Schoengold nurse practitioners. During the time I was on this program I also incorporated rollerblading, daily walks and light weight training into my program. Unfortunately in June a back problem I have been experiencing for many years related to my weight became an issue again and I was limited in my movements and restricted in the area of exercise. Dr. Edward Venn-Watson can provide documentation of the diagnoses and treatment if you so wish to review it. I continued with the “points” plan but without the option of exercise the weight crept back on. I stopped the program on Sept 7, 2004. This information was to be resubmitted to SCMG for consideration within the 30 day period allotted. However when I called SCMG (10-22-04) to make sure this information had been resubmitted they had no new information on file. I finally received a return call from my PCP’s office (10-27-04) who told me it was too early to resubmit and I had to convince them it wasn’t and that they only had 30 days to resubmit the request with the new information. They assured me it would be done. I stopped by my PCP office on Monday, November 1, 2004 to check on the status and learned that still nothing had been submitted. At this time I asked the nurse, Veronica, to hold on to the referral request so I could get another letter from my orthopedic doctor, Dr. Venn-Watson, one which more clearly stated my diagnoses. She agreed and on Thursday November 3, 2004 I dropped the letter off at my PCP office and told them to go ahead and fax the request. I followed up with SCMG the next afternoon (11-04-04) to see if it had been received and SCMG said nothing had been updated in the computer system and to check again the following week, for it may take a couple of days or the status to be updated. I also called my PCP the same afternoon to check to see if I could take the prescription pill Difucan safely while I was breastfeeding. Somehow this message got taken incorrectly and was interpreted that I was pregnant, not breastfeeding, and the entire referral was scrapped since a pregnant woman cannot have bariatric surgery. I didn’t find out about this mix up until I called SCMG back the next week(11-10-04) to see if I had been updated in the computer and told that still no new information had been received. When I called back to talk to the PCP office I was informed they hadn’t proceed any further with the referral since I was pregnant. Once the shock wore off I assured the nurse I was NOT pregnant and the information had to be faxed that after noon as it was the 30th day. I was lead to believe it would be done but, to my dismay, when I called for reassurance on Friday November 12th I was let down again finding out the office had just sent the fax in shortly before my call. I did everything in my power to follow the directions and time line I had been advised of by the very helpful customer service reps at SCMG but my intentions and resolve to get this done correctly were defeated by my PCP office and staff. On November 12, 2004 I was informed they faxed in an entirely new referral request, this time supposedly including all of the proof and notes showing my 6 month weight loss supervised by both Kay Bradshaw PAC and Maureen Flemming NP, for Dr. Schoengold. Again I followed up with phone calls to SCMG and received news on November 23, 2004 that this request had also been denied and for the same reason. I found out that the case had been closed and I would no longer be dealing with the medical group and had been sent back to the health plan (11-29-04). I spoke to another wonderful representative at Sharp Health Plan (SHP), Kevin, who advised me of my right to appeal and gave me the general information I would need to get started. He also explained to me that the referral could not be denied twice for the same reason and that is why it is closed at SCMG and now being handled by Sharp Health Plan.
Through out this experience I have been open and wiling to do what was asked of me to assure a quick approval. My husband and I are the carriers of our medical insurance and pay over $1,000 a month for our family and one employee. Some of the weight loss methods that were recommended as appropriate and fitting within the guidelines would cause a great financial hardship on our family. I have been seeing a counselor, Dr. J. Lessner, who specializes in food issues and eating disorders. She supports my decision to have this surgery and believes I have tried every avenue to take the weight off and successfully maintain it and failed. Beyond the financial hardship another diet attempt would cause my family I am concerned about what my two young daughters would learn seeing their mother struggle, yet again with the effects of yo-yo dieting. I have attended an informational seminar and done many hours of research, meeting with both patients who praise the surgery and those are convinced they made a mistake. I am aware of the risks and the benefits. So far Sharp has been very accommodating and we value that. Please consider all aspects of this request and all the history involved
Thank you sincerely for your time and consideration
__________________
 QueenB
260/245/160/143
highest/suregery/goal/current
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QueenB
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