Health America denied my surgery in Dec (I did it anyway-self pay) I hired Walter and Kelley Linstrom from Obesity Law to assist in my final appreal (I appealed twice myself). Found out this week that HA will REIMBURSE me for all charges and cover me for fills, etc.

My advice to those of you fighting for coverage is DO NOT GIVE UP (I almost did after my second appeal). The BEST thing I ever did was hire Walter and Kelley for my final. They were wonderful.

You can reach them at:

walter@obesitylaw.com or kelley@obesitylaw.com

P: (619) 656-5251

F: (619) 656-5254

Best of Luck all. Contact me if you have any more detailed questions!!!

Congradulations!!!!!

You GO GIRL!!!! good job....

:help: I've exhausted all my efforts and my health is quickly fading. I'm 35 yr. old, 5'5 inches with a BMI over 60 and plenty of health problems. I haven't been diagnosed with diabetes yet but my latest labwork this past week shows my insulin levels are too high. The doctor says it would be better if it were around 10---my insulin level is 20.6 and I have gained 34 lb. within the past 30 days. My insurance company which is BCBS of Tennessee says 'their doctor' says Lap Band surgery is not medically necessary for me and that now I must be under a physician-supervised diet for at least six months before they will reconsider. And the psych evaluation that I've already paid out-of-pocket to have per their request is no longer valid--and I passed it with flying colors. I sent my letter of appeal to them the first of this past April. I received a denial letter at the end of April stating that BCBS of TN had rewritten their weight loss surgery policy and the criteria for this surgery is now even tougher. I'm tired and my health is failing. I just need a helping hand...that's all...a helping hand. God help me do what I need to do to survive. Anyone who may read this thread, please say a prayer for me and for my insurance company...Thank you and may God continue to bless you all.:cry

:youcandothis:Way to kick some butt Maggie!!! So happy for you.

Mona ~ Bless your heart!! Here's a hug for you. :confused: I just do not like the big dogs of insurance having so much power over our lives. I understand there must be rules, but I just hate this for you. Maybe you should check out the websites Maggie listed in her post. Keep us informed and good luck sweetie!!!

Mona,

You stated you have health problems, but for insurance purposes they have to be stated along the lines of comorbidities -- Hypertension, sleep Apnea (some insurance companies don't consider this one), arthritis, diabetes mellitus, gastroesophageal reflux disease (GERD), etc.

Read the BC/BS policy with your OWN eyes to find out what constitutes "medically necessary." The BC/BS doc may be stating your case within policy guidelines, and depending on how stringent those guidelines are, the doc may be correct. Also, get a copy of EXACTLY what your doctor submitted to BC/BS. Then, find another doctor who can help you state your case within the policy guidelines to gain approval.

:help: I've exhausted all my efforts and my health is quickly fading. I'm 35 yr. old, 5'5 inches with a BMI over 60 and plenty of health problems. I haven't been diagnosed with diabetes yet but my latest labwork this past week shows my insulin levels are too high. The doctor says it would be better if it were around 10---my insulin level is 20.6 and I have gained 34 lb. within the past 30 days. My insurance company which is BCBS of Tennessee says 'their doctor' says Lap Band surgery is not medically necessary for me and that now I must be under a physician-supervised diet for at least six months before they will reconsider. And the psych evaluation that I've already paid out-of-pocket to have per their request is no longer valid--and I passed it with flying colors. I sent my letter of appeal to them the first of this past April. I received a denial letter at the end of April stating that BCBS of TN had rewritten their weight loss surgery policy and the criteria for this surgery is now even tougher. I'm tired and my health is failing. I just need a helping hand...that's all...a helping hand. God help me do what I need to do to survive. Anyone who may read this thread, please say a prayer for me and for my insurance company...Thank you and may God continue to bless you all.:cry

:help: I've exhausted all my efforts and my health is quickly fading. I'm 35 yr. old, 5'5 inches with a BMI over 60 and plenty of health problems. I haven't been diagnosed with diabetes yet but my latest labwork this past week shows my insulin levels are too high. The doctor says it would be better if it were around 10---my insulin level is 20.6 and I have gained 34 lb. within the past 30 days. My insurance company which is BCBS of Tennessee says 'their doctor' says Lap Band surgery is not medically necessary for me and that now I must be under a physician-supervised diet for at least six months before they will reconsider. And the psych evaluation that I've already paid out-of-pocket to have per their request is no longer valid--and I passed it with flying colors. I sent my letter of appeal to them the first of this past April. I received a denial letter at the end of April stating that BCBS of TN had rewritten their weight loss surgery policy and the criteria for this surgery is now even tougher. I'm tired and my health is failing. I just need a helping hand...that's all...a helping hand. God help me do what I need to do to survive. Anyone who may read this thread, please say a prayer for me and for my insurance company...Thank you and may God continue to bless you all.:cry

Mona: With a BMI over 60, any insurance company denying bariatric surgery is either foolish, unethical, criminal, or uncaring (or any or all of the above) and deserves to be reported to the state regulators and maybe sued in court.

They are gambling that you will die before having to have medical treatments that would eclipse the cost of bariatric surgery. If the Tennessee state insurance regulators will not step in, it is time to write to both your Tennessee state legislators and to your US congressmen. Each person in this country has one state Representative, one state Senator, one US Representative and two US Senators. Not knowing their e-mail addresses is foolishness on the part of any US citizen.

US House of Representatives

US Senate

State Legislatures

I noticed that you are a person who believes in the power of God. Many of our elected officials also claim to profess that belief. Let's see if contacting them will get them to prove whether they really are "Pro-Life" or actually "Pro-Big-Business".

Health America denied my surgery in Dec (I did it anyway-self pay) I hired Walter and Kelley Linstrom from Obesity Law to assist in my final appreal (I appealed twice myself). Found out this week that HA will REIMBURSE me for all charges and cover me for fills, etc.

My advice to those of you fighting for coverage is DO NOT GIVE UP (I almost did after my second appeal). The BEST thing I ever did was hire Walter and Kelley for my final. They were wonderful.

You can reach them at:

walter@obesitylaw.com or kelley@obesitylaw.com

P: (619) 656-5251

F: (619) 656-5254

Best of Luck all. Contact me if you have any more detailed questions!!!

Maggie,

Would you mind if I asked what the cost was to retain an attorney to appeal?

Thanks,

Rachel

sorry it has taken me so long to get back. my computer is down at home, i have not had time to get it rolling again. it cost 1500 to hire kelley and walter for your appeals (approxiately). it was worth every dime. talk to kelley first before you appeal. she will tell you realistically if you have a chance. since medicare is paying for lapband now, it makes your chances much much better. feel free to pm me if you want.

MAGGIE YOU ROCK !!!!!!!!!!!!!!!!

Congratulations to you whoooooooot!!!! and a ha cha cha ~

Maggie - Did you have an exclusion in your policy?

not sure what you mean by an exclusion...please explain.

Did your insurance policy state that it does not cover or excludes surgery for weight loss?

Congratulations, Maggie! I'm wondering the same thing as Kim--what was the initial reason for your denial? Was it because there was an exclusion in your policy or was there some other reason?

Thanks for any information. Every time someone one wins one it gets a teensy bit easier for everyone else!!

i was denied because they called the lap band "experimental" after my third appeal they agreed that it was needed for me.

i will try to get my stuff together and post it out here for all of you....remember..you have to fight to win!!!

Maggie what GREAT news!!!

I'm so very happy for you!!

*happy hugs*