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

Sunday, February 12, 2012

Sunday Thoughts.

So it's February 12 and I'm down 15 pounds since returning from Christmas vacation.  I'm glad!  I gained 25 pounds in late 2011 due to self pity and gorging, and there are only 10 pounds of that left to lose!  I can't "weight" to be back down to where my lowest was, then moving forward on to the coveted "onederland."  I know it's within reach, and if I continue to lose approximately 2 pounds a week, I'll be hitting my goal weight of 169 (exactly half of my starting weight) right around my 32nd birthday on August 28.  I've never been as motivated in my journey as I have been in 2012, and the work is paying off!

I've spent much of 2012 traveling for work, and I'm proud of my ability to generally stay on track with my caloric intake plan (no more than 1,600 calories in each day), my daily burn goal (at least 2,600 calories per day), taking my daily vitamin and getting my water intake (at least 8 glasses a day).  The "no excuses" theme of this season's "Biggest Loser" reminds me each week that traveling, a busy schedule, daily stresses, etc. are no reason to make an excuse.  I go to the gym, even if/when I don't want to.  I travel with my workout clothes, tennis shoes and MP3 player...because every hotel has a gym.  I choose healthy foods, even though restaurants offer a variety of unhealthy choices.  Overall, I'm proud of what I've done so far in 2012.

The ultimate goal, of course, is to make healthy choices and exercise a habit in my daily life...I think I'm on the road to being there!  I'm reminded that although some of my former food choices may be delicious, the temporary "mmmm, yummy" isn't worth the weight gain or former/current state of my body.  I'm in this for ME, and it's about damn time I take responsibility for my own journey.

My boyfriend says he's never seen me so motivated in my diet and exercise (he's know me since right around the time I got my initial consultation for my LapBand surgery), and I'd have to agree with him!  I don't know what exactly has kicked it into high gear and focus for me, but I'm determined to keep it!  I can and will reach goal weight in 2012.

I can't even IMAGINE being in onederland, let alone hitting my goal!  I honestly don't remember when I was last under 200 pounds...but I'm going to guess it was sometime in high school...I'm pretty sure I hit 200 then.  Wow.  I'm going to look BETTER than I did in high school!  Completely.  Insane.  Not only will the size be smaller, but the cardio and strength training will mean that I'll have a better and healthier body than I did in high's so within reach!  And?  It's still absolutely staggering for me to think about.