Saturday, February 18, 2012

Take that, bishes.

Finally composed the appeal letter to my insurance company...they've denied the removal/replacement of my LapBand.  What do you think?

To whom it may concern:

On November 30, 2011, I received a letter from Anthem denying a necessary surgery based on the fact that my “health care plan does not include benefits for services and supplies related to obesity or services related to weight loss or dietary control, including complications that directly result from such surgeries and/or procedures.”  While I recognize that such services are exempt from the insurance I carry, I am appealing the decision not to cover the treatment below based on two factors:

Member: Joia D Jones (ID #xxx)
Health Plan: Anthem Blue Cross & Blue Shield
Case Number: xxx
Servicing/Ordering Provider: Pinnar Robert L MD
Treatment Code: xxx
Treatment Description: Surgical Laparoscopy – Remove & Replace Gastric Band

Primarily, I am appealing this decision on the basis of the complication being a pre-existing condition.  I originally had my Gastric Band implanted in the State of California, covered by the Anthem insurance I had at my previous job.  Plagued by medical issues from a complication with the Band that my California doctor refused to treat correctly, I immediately saw Dr. Pinnar upon moving to Virginia and starting a new job with a new company.  Dr. Pinnar’s records will show that the complication necessitating the treatment above existed when I arrived in Virginia.  While I worked with Dr. Pinnar from August through December of 2011 to “fix” the situation without surgical methods, his documentation shows the complication was unable to be fixed.  At this point, the treatment listed above is medically necessary to correct the complication that pre-existed when I began membership under this insurance plan.

Furthermore, this surgery is medically necessary in order to improve my quality of life.  Having a permanently slipped Gastric Band means that my stomach has permanently herniated above the slipped Band.  I am only able to eat a limited quantity of very specific foods in order not to upset the herniated stomach, and typically end each “meal” by regurgitating the food I’ve attempted to eat – witnesses both at home and work can attest to this fact.  This constant regurgitation leads to popped blood vessels around my eyes and cheekbones, and severe discomfort for hours on end.  However, these side effects are minimal compared to the danger that living with this pre-existing complication could present.

In early October 2011, while I still had a small amount of fluid inside the Gastric Band, a regurgitation episode led to blockage in the herniated stomach.  I became severely dehydrated, regurgitating every sip of liquid I attempted to keep down.  Dr. Pinnar drained the remaining fluid from the band and I spent three days at home, away from work, unable to sip even water until the end of the third day when the swelling and irritation had subsided.  While I survived that bout of dehydration and blockage, the saving grace was that I still had fluid in the Gastric Band that could be drained to alleviate the situation.  Since that time, the Band has been completely empty – a single piece of food could cause an equitable blockage, with no remedy left other than emergency surgery to remove the Gastric Band.  Dr. Pinnar has made it very clear that I am a “ticking time bomb.”
Dr. Pinnar did a “peer to peer” appeal with you on my behalf in December 2011, explaining the same surgical necessity.  We were informed that not only would the surgery not be covered due to exclusions in the policy, but that if an emergency surgery were needed as described in the previous paragraph, that surgery would not be covered either.

In light of the facts that this surgery is medically necessary and corrects a pre-existing condition, I urge you to reconsider your denial of coverage.  Further denial of coverage will only serve to prolong the inevitable.  I am ready to take this case to the Commonwealth of Virginia’s Bureau of Insurance if I cannot get a satisfactory response from you. 

Joia D. Jones


  1. OMG... This is awful, I am so sorry that you are doing through this, it sounds so frustrating. I hope you get the answer that you need to help your health and quality of life.... until then keep the faith.

  2. The letter is great! Fingers crossed for you!