Denied for the 3rd time

[khelm32 52]

I just got off the phone with the insurance and they have denied for the third time. I'm not sure what else to do at this point. I'm waiting to hear back from the nurse coordinator I have been working with. I literally have met all the criteria that they have asked for or asked me to do, and still no approval. Why do they have to make it so hard for people to get healthy.

[MsGal 104]

What was the reason for the deny? Lisa

[khelm32 52]

So over the last 10 months I've been going through the process to get approved for the lapband. I've done the 6 month supervised weight loss plan, had a sleep study, completed all paperwork and checkups needed for the procedure and what the insurance is stating is required. I received my 3rd denial from the insurance last week. Yes, I said 3rd. I have exhausted all appeals with the insurance. Everything they've said was required for the approval, I have done. The first denial said it was a cosmetic procedure and it was not covered. The second denial said because my BMI was at 37.5 at the time the paperwork was submitted, I would need to have a co-morbidity of either diabetes or sleep apnea to qualify. I had the sleep study done and was diagnosed with mild sleep apnea with a recommendation of weight loss. I received the 3rd denial stating that the co-morbidity had to be moderate to severe. My employer is self insured so the insurance company only coordinates the benefits according to the contract set forth by my employer. My last step is to appeal through my employer, which I have done. I am now waiting for their decision.

I'm feeling discouraged and don't really know where to go from here. If the insurance won't cover this, then I will have to let go of that option for weight loss, which I've been seeing as my last resort. I've literally tried everything and all my doctors recommended this procedure for weight loss. Since I have tried everything, read every book, etc, I'm feeling lost as to where to even start or what to do next to lose weight. I'm hoping my employer will come through and overturn the decision, but considering they aren't going to want to fork out the money, I have little faith that will happen, so then what?

[I♡BypassedMyPhatAss♡ 800]

Keep fighting, advocate for yourself. I would talk to the insurance coordinator at your WLS office, she has probably seen this problem before. Insurance companies need to realize that this surgery would benefit not only you, but them as well, since you're not extremely over weight, so if you nip it in the bud, you could save them big $$ by not developing comorbidites in the future. Best wishes to you

[tiggergramma 129]

If you absolutely, positively cannot get the surgery covered with your insurance; there are a couple of possible options, neither of which is perfect, but may be worth looking into. 1) Check in to the new insurance markets that are being opened up to folks without coverage. It may be that you can afford to get your own insurance that will cover the surgery and followup adjustments. 2) Use hypnosis. There are programs now that use the suggestion of stomach compartmentalization, a la lap band, that suggest you will be full with 1 cup of food and not have hunger for 4-5 hours, etc., basically fooling the mind into thinking you have had the surgery. Katie Evans has one available on CD that you would listen to daily for 21 days...She has Living Lite, which you can check out here: http://www.livinglitenow.com/

I recently attended a 3-hour session for weight loss and exercise motivation because I felt like I needed a little extra help with the band. (my band IS working, it is just so bloody slow that I am frustrated) Anyway, I know hypnosis does not work for everyone, but I know that it does work for me; I used it to quit smoking almost 20 years ago and it worked great. I also use self-hypnosis methods for relaxation and stress, or to get my heart rate up while exercising.

Good luck to you! I hope you finally can talk sense into your insurer!

[skb123 308]

I just got off the phone with the insurance and they have denied for the third time. I'm not sure what else to do at this point. I'm waiting to hear back from the nurse coordinator I have been working with. I literally have met all the criteria that they have asked for or asked me to do, and still no approval. Why do they have to make it so hard for people to get healthy.

My daughter has Kaiser and she has been denied twice, she has gotten an attorney to fight for her. The attorney said that 90% of the time they get approved. So you might need to go that route. It's surely worth looking into.