Denied by Healthnet ***

[Petunias 2]

I have been denied twice in the last 2 days. The reason I was denied is that my BMI is only 34.8. I lost 30 pounds last year and have been gaining it back slowly. I thought that I'd head it off before it reached more than I had lost. Guess I thought wrong. I need to gain another 6 pounds in order to qualify and I don't really want to. I already feel horrible at my current weight..

[MelindaH 3]

I have been denied twice in the last 2 days. The reason I was denied is that my BMI is only 34.8. I lost 30 pounds last year and have been gaining it back slowly. I thought that I'd head it off before it reached more than I had lost. Guess I thought wrong. I need to gain another 6 pounds in order to qualify and I don't really want to. I already feel horrible at my current weight..

Hi, I am really sorry, hon. Do you have any co-morbities? I have heard that ***'s are the worse. I would not gain the six pounds. Has your doctor talked to them directly? You might consider filing an appeal with the insurance comission of your state.

All the best to you,

Melinda

[PWoo10 7]

I'm sorry I have never heard of anyone getting the surgery at a BMI under 35. Mayber if the FDA new guidlines sway insurance to change their minds you will have better luck. I have been trying over 2 years to get a lap band and I'm at 38.8 and I get denied because I only have 1 co-morbidity. Good luck on your journey. Please keep us posted.

[Petunias 2]

Hi, I am really sorry, hon. Do you have any co-morbities? I have heard that ***'s are the worse. I would not gain the six pounds. Has your doctor talked to them directly? You might consider filing an appeal with the insurance comission of your state.

All the best to you,

Melinda

Thanks for the well wishes. Yes I will appeal, I'm going to get copies of my medical records for the last 5 years so I can have all of my facts straight. My BMI was almost 38 (and was for some time) before I started my last diet. I guess I jumped the gun in going to the doctor too soon. I just started to panic as I started to gain back the weight I lost . And that usually means gaining a few more pounds than I lost too.

I do have co-morbities, high chol, mild sleep apnea and gerd. Thankfully, I don't have diabetes or high blood pressure-yet anyway.

[lizzy2150 3]

Ever considered carrying rolls of quarters in your pocket when you get weighed at the doctor's?

[Cocoabean 430]

Just a word of caution if you are considering gaining the few pounds. Some companies require a BMI 35 or over for X years. So the fact that you are under now could start the clock at the point you go over.<br><br>Read your policy carefully. It truly sucks that we take positive steps to improve our health, have some success, need some help, and get shot in the butt for it.<br><br>In your appeal, be sure to mention the FDA's lowering of the BMI standard for lap banding. It might not make a difference, but throw everything you can into the letter! www.obesitylaw.com might have some info to help.<br><br>Best wishes!!!

<div><br></div><div>Edited to add this link:</div><div><br></div><div>https://www.healthnet.com/static/general/unprotected/pdfs/national/policies/Bariatric_Surgery_Jan_11.pdf</div><div><br></div><div>I am not sure if the above link applies to all Healthnet policies, but it does say a 2 year history. But it doesn't say in the past two years...so you can make the point of 2 years out of the previous 5 if that is the case.</div><div><br></div><div><p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">For at least 2 years or greater, the patient has clinically severe obesity (morbid obesity) defined by <b>either </b>of the following:</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Helvetica">• •</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">Body mass index (BMI)* >40 kg/m<span style="font: 6.5px Verdana">2</span>; or</p><p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><br></p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">BMI of > 35 kg/m2 and < 40 kg/m<span style="font: 6.5px Verdana">2 </span>with <b>one or more </b>of the following co- morbidities which are generally expected to be improved, curtailed or reversed by obesity surgical treatment:</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Severe, active coronary artery disease</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Obesity-related cardiomyopathy</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Congestive heart failure</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Obstructive sleep apnea with use of CPAP or polysomnogram showing apnea-hypopnea index (AHI) ≥ 15 per hour</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Pickwickian syndrome</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Type 2 diabetes mellitus</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Clinically significant asthma</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Chronic venous insufficiency with pain on weight bearing and persistent edema; or</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Respiratory insufficiency, as evidenced by pCO2 > 50 mmHg, FEV1/FVC < 65%, or DLCO < 60%</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Hypoxemia at rest, as evidenced by pO2 < 55 mmHg on room air</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Severe gastroesophageal reflux disease (GERD)</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Severe pain and limitation of motion in any weight-bearing joint or the lumbosacral spine documented by physical examination in association with radiologic findings showing degenerative osteoarthritis</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana"><span style="font: 10.0px Helvetica">→<span class="Apple-tab-span" style="white-space:pre"> </span></span>Patient has <b>at least one </b>of the following:</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">Bariatric Surgery Mar 11</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">2</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">a.</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">b. c.</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">3.</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">d.</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">e.</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">f. g.</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">Hypertension(bloodpressure>140mmHgsystolicand/or > 90 mmHg diastolic measured with appropriate size cuff) that has not responded to medical therapy Firstdegreerelativewithpremature(age<50) cardiovascular disease</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">Hypercholesterolemia > 240 mg/dL that has not responded to medical therapy</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">Hypertriglyceridemia>400mg/dLthathasnotresponded to medical therapy</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">Lowdensitylipoprotein(LDL)>130thathasnotresponded to medical therapy</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">Highdensitylipoprotein(HDL)<35thathasnotresponded to medical therapy</p>

<p style="margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Verdana">Impaired fasting glucose > 125 Pulmonaryhypertension</p></div>

[Petunias 2]

lizzy - I wish I would have put a roll of quarters in my pocket or maybe a block of lead! LOL

Cocaabean - I like the way you think! I'm definitely going to use that reasoning in my appeal letter. Thanks a bunch! And you are right that gaining the weight won't do much good currently. I was getting really depressed thinking about gaining that weight.

I'll keep you posted....