c945105

Thanks Bayougirl.. You know you did inspire me as I had just called yesterday to set up going self pay feeling defeated after 2 appeal denials that I will try the last thing which is the third party review. My biggest fear honestly is not the intial outlay but any complications and fills (not that I wouldn't love not to have to pay the outlay). I work for AT&T and I feel they did not write the policy well and they are trying to be subjective after the fact and deny unless you have a serious co-morbidity. I think the Dr. did a nice job with a long 2 page letter outlining the medical necessity and my medical issues. My two appeals I tried to be very specific too why I thought I qualified. The AT&T policy states only Covered Person must have a minimum BMI of 40 (I do as of now) Covered person must have documentation of a diagnosis of morbid obestity for a minimum of five years from a Physician. It has no stipulation written even about the co-morbitities which I pointed out but I also point out that I have several (albeit not as severe as the last letter Dr. pointed needed to be (this Dr. at UHC said I needed to have type 2 diabetes, cardiovascular diseasae, life threatenting cardiopulmonary problems). So here is my big arguement to them there is no defintion of morbid obesity here and I certainly feel like being with 10 pounds for 8 years of a BMI of 40 should qualify. The only reason I was not over a 40 probably is becuase most of the time was either on phentrimine and constantly worked hard at many diets (insulin resistance I have makes it even harder to loose weight). I pointed this out but I'm thinking maybe if a third independent party which is where it goes now will look at it maybe they will see the point. I don't like they way they can just interpret a probably poor written policy the way they want. I think they should change the policy to write out specifically then what needs to be met. If this is what they wanted to cover then they sure surely define much clearer what morbidely obese is and also put in co-morbidities as there is absolutely nothing stated about co-morbidities. Anyhow, you have made me rethink this and at least send to the third party. I hate putting off any longer as need to make this important change in my life but have to weigh things. My father died of copd last year and my mom has type 2 diabetes I know for me I must do this to be healthy and I wish the insurance company would see this is going to save them big time in the long run. Thanks for letting me rant.... off to writing my letter. Thanks again and I wish others not so much issues with insurance. Cyndi p,s, I have experience with appels with them as have a son with significant dev delays which they approved ST and OT and then deny claims.. I have won all my appeals for that but it's so frusturating as I had to take him out of therapy while fighting as I didn't know if I would win. They make it so hard and it's only hurting the patients.

I have same plan too. When Dr. sent in letter I think it was within a few days and I have appealed twice and they have gotten back within 2 weeks with the sad news of denial! I am a BMI of 40 but was just below the last 8 years (within 10 pounds) and have what I tried to argue co-morbidities of high cholestoral, high triglicerides, and insulin resistant (that I take metformin for) but they have come back and said my co-morbidities are not serious enough like diabetes, sleep apnea. The policy I have says "Currently BMI of at least 40 and must have been morbidly obese for 5 years". I tried to argue the policy doesn't define 40 as morbidly obese and being with 10 pounds I think should qualify. Also that it doesn't even specify co-morbities under it but I felt I had them anyhow.... So anyhow I feel they are very black and white about it. I felt my arguement was pretty decent but looking like I will need to go to self pay sadly as I don't want my health to deteriorate (which it will.. there is no doubt I will have diabetes soon as my mom has it and my insulin resistance is leading there) and not willing to keep myself at a BMI of 40 for 5 years on purpose!... Best of luck and if you meet their criteria I think you will be fine.

I'm in NW suburb of Chicago and it's 17k here. I'm a BMI of 40 but was just below it for 8 years (within 10 pounds). I have high triglycerides and cholesteral and insulin resistance but no "major" comorbidities so UHC has been denying my appeals. So sad but think going with the 17k as really feel like this is the tool for me to help get healthy.