Hi all,

I am so upset. I just found out today that I was denied the surgery. They said it was not medically necessary. I have a BMI of 39. If I'm not fat enough, that is truly pathetic. My surgeon's office is appealing the denial. Is that usually the course of action. I was thinking about writing a letter in addition to the surgeon's appeal. What does the surgeon's office do as far as appeals go? I need help. Please let me know what you all think I should do. I was scheduled for July 11th and now who knows when I'll get it done.

Emily

Well, of course after telling you about my denials, they are trying to deny me again..told me that the two people who verbally told me it was coverd and I could go ahaead and plan my pre-op appts, were mistaken and they were only telling me I fit the insurance companies definition of morbidly obese. I am so pissed off I cant see straight. I spent a couple hours with the insurance people conferencing them in on my surgeons, pcp and the pre certification department. I am leaving tonight for a short vacation and will find out when I get back what they decided and if I need to cancel everything..I have my pre-op on the 11th so i am sure that will get screwed.

The other day the insurance lady was like "I have to run this by 'the approver'"...ummm..she sounds like a demon like figure in a room full of fire with a big red denial stamp, laughing every time she slams down the stamp. The Approver...what a job title!

Emily, Who is your insurance company? I recently saw on a website a post from someone who works with Blue Cross who might be able to help.

NancyRN

My insurance company is Health Net. Let me know.

em

:angry I am so sorry to hear about the denial. I was denied in March and the surgeon's office does not do appeals so I appealed. Someone told me that you have to have a couple of other things wrong with you. My BMI was 35. But, my blood pressure was elevated and I have sleep apnea. I went to my regular doctor and she documented (on letterhead stationary) that my blood pressure was high (and told what it was) and that I suffer from sleep apnea. I even made copies of the prescription for Ambien that I had. I sent the appeal letter and the letter from my doctor and within a month I was approved and I had the surgery May 11, 2006. I was really happy. Good luck to you and let us know what you find out.

Hi Scribby,

I was verbally told too that I was approved back in March and got a letter in the mail that said I was denied - that I did not fit into their description of morbid obesity.

Also, I was saying in my last message that you need 2 other things wrong with you and some of the things are high blood pressure, sleep apnea, and diabetes. There are a few others, I just can't remember what all of them were. Good Luck!! Hang in there!

:angry I faxed them 20 pages to two different numbers today and stayed on the phone with someone until it came off their fax machine. I had written a note on the cover page that more documentation would follow. They called me back and said they were confused about the note. I explained that I would send more office notes from two other doctors under seperate cover. The girl said, 'oh she just wanted to know if she should go ahead and scan it before she denies you again' Am I hearing correctly? I asked 'does she plan to deny me again?" then the girl started crawfishing out of her comment.

I am ready to throw in the towel. I am 49 years old and have a BMI of 49. At this rate I may not have much more time...:cry

Then I read here that some people try for a year and get approved. I hate to go borrow 11K to self pay in Mexico, especially with the premiums we pay. I will try again until .... when?? I have not actually received a letter of denial. They just keep telling me they need more...

You may get approved. Keep trying. Do you have comorbitities? I was thinking of self paying myself. I love my surgeon. Self-paying for a top NYC surgeon may run around $23,000. I don't know if I would be comfortable going anywhere else now. I don't know. I want to see what happens with my first appeal. I will appeal for the second time, but with an attorney. It seems that almost everyone who self pays goes to Mexico. I have heard wonderful things about the Dr. there. I thought it was $8,000. I could be wrong.

Good luck.

Em

Thanks Em, I plan to keep trying. Self pay in Houston is about 15K and they are quoting me 10K for Dr. Roberto Rumbaut in Monterrey this summer. I have PCOS and impending problems besides morbid obesity with that. Thank you for the encouragement. So, are you appealing with an attorney then?

If my first appeal gets denied, I will absolutely hire one. I have already contacted his office but, he hasn't returned my phone call yet. I want to see if they approve this appeal. My surgeon and I both wrote another letter. We'll see what happens.

Good luck.

I recently saw on a website a post from someone who works with Blue Cross who might be able to help.

NancyRN

:help: I have BCBS of Texas TRS Ativecare. Do you know someone who might be able to help?

His name is Gary Viscio. Below is the website. I think he's been away for the last few days. He hasn't called me back yet.

em

http://www.obesitylawyers.com/sub/index.jsp?contentid=ErKkQtKkPWd5ZBCMXKGAJL67

Emily, When I first started the process of trying to get approval for lap band I too was at 39 BMI. I knew my chances for an approval would be much better if I gained 15 more pounds. I know that sounds awful but maybe it would work for you if you gained a little bit more weight just to get you up to the 40 BMI. After all, we all gain weight as time goes on and the insurance company cant prove that you gained it just to get approval. Just a thought.

Emily, Mert, and anyone else who needs help with insurance:

Here are some ideas for finding info. on your insurance company and help on appealing a denial:

1. Go to www.obesityhelp.com. Find the aqua band across the top and click on "insurance" and then on "appeal help".

2. On the same aqua band, click on "Q and A" or "FAQs" (I can't remember exactly which one). Click on "search keyword". You have 2 options: enter "insurance" and you'll go to a huge list of comments organized by insurer name. Or don't enter any keyword, but look at the list of topics below the empty entry site. On the left side, click on "preoperative insurer research" and then look for your specific insurer.

3. On the ObesityHelp homepage, look across the top and find "forums".

Click on it and go to the 4th category, on the bottom of the page. Click on "insurance help".

4. On this lapbandtalk site, check out the forum called "insurance".

If you go to these areas, would you post on whether or not they're helpful to you?

Thanks,

NancyRN

Dear NancyRN, Thank you so much for the resources and encouragement. I went to the aapeal letter and the long insurance list that you sited. It looks like others with bcbs of tx trs activecare have been approved. With that appeal letter I am armed and ready. Thanks again for the support. I needed that. I am blessed to have info and folks available to help me.

Thanks EM, I will keep Gary in my notes for future reference. Keep me posted when he contacts you. I feel hopeful again and ready for another round!