DreamsOfSkinny

Here at the appointment anxiously awaiting the doctor

Good luck

I have it too... I actually had norovirus (nasty stomach bug) for a week' date=' just started feeling better from that and then came down with this flu and it's pretty bad. . GRRRRR.. oh well, at least it broke my stall. Feel better soon.[/quote']

I hope you feel better!!

Surprising but every employer plan is different. Good luck with everything!

Thanks!!

Hi Dreamofskinny' date=' my info will be submitted next week to UHC and i will let you know how it goes![/quote']

Thanks and good luck!!! My ins. Received mine on the 9th (per my certified receipt) but they haven't logged it into the system yet. I'll call again tomorrow

Ughh! Well I'm waiting on the news from my 2nd level appeal and honestly hoping this flu will help me in needing to lose my 10 lbs per doc. Lose my appetite. But feel horrible none the less.

Hope everyone stays well during this crazy flu season!!!

I wasn't told about it initially. I accidentally found it while googling about UHC and bariatric surgery.

Well i just called and their service is very limited for me. Only really to prevent "clinically severe obesity" patients from having surgery. Diet talk, etc. No help with UhC. But thanks anyways for telling me. I'm still wondering what the PHI info is that they should be sending me.

A lot of positive thoughts, visualizing my goal to obtain it, and prayers!!!

Optum Health is a care coordination service for long term medical issues' date=' pregnancy, cardiac, kidney, bariatrics, asthma, that sort of thing. I am not sure if every UHC plan has it but mine did. They verified my coverage and sort of pre-qualified me. They were willing to provide me with a list of surgeon's but I went in with a name. In addition I had a RN case manager who contacted me every couple of months just to check on how I was doing. She was the one to call me with the final authorization before my surgeons' office could. I have nothing but good things to say about my experience with them and recommend getting in touch if it is available.[/quote']

WOW! I'm so mad now. I was never told about this at all from Uhc! I just literally read through a 500 page SPD and found the info.

Waiting on surgeon office to fax over peer to peer appeal.paperwork I was denied for low BMI with no health issues. Reweighed me BMI is 41 crossing fingers

Good luck!! Are the ins. Saying you need certain BMI for previous 2 or 5 years?

I'm still a part of this group----sadly! Hoping this changes soon. Just overnighted it to my insurance. 16 days in counting for a response!

Overnighted 2nd level appeal package -- haha yes it was about 3" thick.

I'm still a part of this group----sadly! Hoping this changes soon. Just overnighted it to my insurance. 16 days in counting for a response!

Okay I called the insurance company BCBS il and at that time i was told that I was Denied. Bummer! They said that my company excluded WLS. After telling me for several months that they cover it.

Wait. I called them several times afterwards to find out why. And i also called my Hr lady too. I asked BCBS for a copy of the policy that said my company excluded WLS.

Finally after getting the run around they said I'm approved!

I'm so excited! But waiting on a written letter of Approval.

Thanks for the support.

How AMazing!!! Did you get approved bc they couldn't produce that document??

HOW FRUSTRATING!!! Reading stories like this makes me actually relieved that I was not covered for WLS by insurance.

I would love to not have to fight but 1) I'm hardheaded and love a debate 2) I don't have the money to self pay

Good for you! ! I hate dealing with insurance. Seems like they always win. Go get 'em girl! !

Ty!! After this I think I can put together an e-book for others going through appeal process.

I called the Department of labor today They said if I'm still denied after this level to contact them again and they'll get involved with my employer. Based on the insurance company denying me for language they say is in my SPD --but actually isn't-- and for my employer nor UHC being able to provide me documentation of where this language is written.

I'd hate to have to go to that level but my employer is leaving me no choice! I also found last night a couple of court cases - one with Uhc self-funded plan for denying someone for obesity surgery. Her plan stated the EXACT same criteria. I included in appeal letter and stated UHC has shown in this case that they never said she needed to have a bmI of 40 for 5 years.

Prayers appreciated and good thoughts!! I also found out that by ERISA standards and my SPD UhC has to give me answer within 15 calendar days.

Not sure what part of Houston you are in but check out the doctors at the methodist hospital/medical center. I had great success with them. Also if your version of UHC has access to the Optimum Health program - use it! It made everything a breeze for me plus if you really have no idea for a surgeon' date=' they will give you a list of ones in-network.

Good luck![/quote']

Ok what is Optimum Health. My UhC never told me about them and they don't have bariatric resources but i received a letter in the mail from them saying I requested privacy documentation. I called and just was told it was bariatric complicated cases team. I filled out paperwork but have no idea who they are.

Well I've left voicemails for the consumer affairs person I talked to at UHC and the new representative past 2 business days with no response. I'm sure my file now reads - crazy b***h keeps calling. Don't call back lol!!!

But I now have finished my appeal letter. 14 pages long plus tons of references. It's an entire package I have to mail off tomorrow - certified that is. I found out that the insurance has violated both ERISA and the Protection and Affordable Care Act, so I kindly put each code and section in my letter as well

My employer is now siding with the insurance company (although it is self-insured) and says that they are adding language to my SPD for clarity. Wait wait wait. According to both aforementioned acts PLUS several court proceedings, if I can prove I relied on my SPD to base my eligibility on then that should be final say AND the employer can only change language with a 60 day heads up to employees. Sneaky bastards.

Here we go again. Under ERISA I should hear a reply within 15 calendar days! NOT business. I'll once again call every other day to check status. Now I need to lose my 10 lbs so when they approve me I can have this darn surgery already.

Thanks

Omg!! I was wondering what happened to you. I hadn't heard from you in a long time. How are you doig?

I weighed this morning and I have officially lost 100lbs!!! Unbelievable! I still have 85lbs to go for goal and 50 to make it to Onderland! I do feel like the next 50-85 is just gravy! I'm so happy and can't even explain how much my life' date=' my attitude, everything has changed. I LOVE myself again! I wasn't sure I'd ever get back to being happy with myself, because I was so disappointed in how far gone I had gotten. This is 100% the best thing I ever did for myself, my kids, my friends, my family, my job, MY LIFE!!!!

Great start to the beginning of the best year ever! Here I come 2013 and beyond!

I've posted some befores and 2 pics taken today (after my walk at the beach trail)....I'm Loving Life![/quote']

You look great! Wow--what a loss so far. Congrats

Hello all! I was sleeved 12/10 and am down 17lbs since surgery. I'm looking to see if there is anyone that lives near me and would like to become occasional work out buddies or attend support groups together. I live in the East Bay of Oakland-San Francisco area.

Oakland!! I'm still trying to get my insurance to approve it. Inbox me.

Surgery date: 8/17/12

Surgery wt: 217 lbs

Current wt: 165 lbs

Total loss: 52 lbs!

(Considering I was pregnant 10 1/2 weeks of the 18 weeks since surgery I am very pleased with those stats

Congrats on the pregnancy. Did the dr. Say anything it being so close after being sleeved?

It's been ages since I got on here to post but I figured it was a good time for an update to you lovely people!

Starting: 247#

Sleeved: 235#

Goal Weight: 155#

Pre-cosmetic (full lower body lift w/breast lift/augmentation) Dec 3' date=' 2012: 136#

- removed 5# of skin, added 3# of implants

Current Weight: 133.6 #

New Goal - don't care about the weight, increasing strength and wanna see my abs (see goal pic)![/quote']

I think everyone is mis-reading this post. But maybe I'm wrong.

Is the goal picture of you OR is it what your new goal is?

Either way you look great!

I was so excited yesterday! I called UHC to again ask where exactly this language came from after speaking with Lindstrom law telling me that ins. Companies can have "behind the scenes" policies and guidelines they don't always share with patients. I talked to a supervisor that was SO nice! He even gave me his FULL name AND DIRECT telephone number. I just had to thank him again for helping me look into this before I submit my 2nd level appeal. He totally agreed with me that this language is nowhere and that I should be approved based on meeting the criteria in my Summary Plan Description. I truly hope he can help shed some light on this.

The consumer affairs person from corporate no longer wants to return my calls. She sent me a letter saying the case is closed for her trying to find out where the language came from for a BMI of 40 for past 5 years. It simply said that this is what it is, and I'd need to show BMI of 40 for last 5 years to be approved. Still no explanation of where this language is coming from. That was no help.

My advocate from work is having a conference call with my employer on Monday along with her boss to see where this language is coming from and why if the SPD has no definition of how they define "morbid obesity", how am I being denied? My SPD only states- must have a BMI of 40. It doesn't say "had" as in past tense for the past 5 years nor does it give any other details of this minimum BMI applies to. On a separate line it states - needs diagnosis from a physician of morbid obesity for 5 years.

I have now asked my Dr. To specifically write the ICD-9 code for this an state this is for the past 5 years. I feel now I should be approved. I've met all 4 criteria but insurance seems to to be wanting to apply the first criteria having a minimum BMI of 40 for the second criteria - morbidly obese for 5 years. Ughhh!! My insurance should have a clearly defined definition!! I think I found a place for improvement for 2013 policy!

Oh yea' date=' I think we have had this discussion before. Pookeyism is right. If they are smart enough to take your money and do your surgery, you would think they would be smart enough to get it past the insurance. I know that I am not going to fight with them too long before I go to Cancun. It's just so much cheaper and a whole lot less headache. And, I know that is exactly what UHC wants you to do. Know what I mean????? No cost to them.....[/quote']

Well I'm going to keep fighting it. I know they want you to give up. And yes, it definitely feels that way but I can't afford out of pocket and I really want my Dr. And any aftercare covered and him near by if there are any issues. The way UHC supervisors were talking, they all were like - just file a 2n level appeal- almost as if it would then have a better chance of being approved vs me fighting them on the pre-authorization, peer to peer, or 1st level appeal.... I'm really hoping and praying for this. I now have 10 pages typed and neatly organized stacks of references and previous documents of this entire journey. Whew! I just want an answer asap once I submit it lol Don't we all?!

Go ahead and research what your next step is should you be denied' date=' and have it lined up...it sounds like your insurance is fighting you hard. Is your doctor being of any assistance? If not find one that will help you. If they are experienced enough to take your money and be trusted with this surgery, they should also be able to be a strong advocate with the insurance process.

Good luck.[/quote']

They have helped and he's written a letter this time with the very specific wording the insurance is denying me for.... So we'll see if that helps. Next step is external appeal and I feel like I'd really just be re-sending the exact same package to them.