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

does anyone have bcbs of new England (MA)...... how are they???? Have your letters come from your pcp or the bariatric surgeron that is going to do your surgery? Do the insurance companies listen to the surgeon that is going to do the surgery or do they go outside and get another bariatric surgeon look at the paperwork without even getting to see the patient in person? From paper what the heck can they tell or see???

Just wondering how it works.

Thanks for the support. My BMI is 39 with Co-morbitities of high cholesterol, chronic hip bursitis, chronic neck and back pain for years in addition to having cervical spine surgery in 2002.

WOW that is absolutely nuts for you not to be approved. The spine surgery, High Chol. and bursitis alone.... should have done this for you! See if you Dr. has put failed back syndrome on your claim.. this should help you. Alot of Dr's miss this!!! so I'm told by my Dr.

I'm not trying to rub it in. but we were almost identical and I just got approved. I had bmi of 39.8 and co morbid issues of failed back syndrome (had a few surgeries.. fused spine), intrathecal pain pump, HBP, back pain, hip pain, bursitis in the hips. I'm just floored that the spine issue wasn't the deal sealer for you! the back is a huge expense to keep treating and if you lost weight.. a lot of those things would probably go.

Mert,

Gary never returned my phone calls or e-mail that I sent him. However, Walter Lindstrom is willing to take my case. I gave him all my info.

Thank you for the update, em1125. I put this in my folder for future reference should I need it. Please keep us posted and let us know what Walter Lindstrom does for you in case you need him. I think things are lookin' good for you. Haven't heard from the insurance co. after they consulted the bariatric surgeon?

I have decided to go to the only doctors and hospital in my insurance network (for bariatric surgery) here in Houston. I have my first appt with the doctor on July 18.

:clap2: :clap2: :clap2: Hoo-ray!!

Good Luck! I'm so happy for you.

I had a dream last night that I had the surgery already and I was 60 lbs. lighter. It was awesome. Too bad it was only a dream. One day.

I should hear from the insurance company Monday or Tuesday hopefully.

em

em1125

did you meet with the surgeon that was actually going to do the procedure on you or just his/her assistant?

I met with the surgeon who will be doing the procedure if my insurance approves it. My BMI is 35.3...I gained a whole 1 1/2 pounds before I weighed in..didn't bump me too much...lol

I hope when the surgeon says "You'll be approved" he means it...its crazy to get all excited then have your heart broken. I'm so afraid of that. I was sooo happy after meeting with him. He of course has to work with my cardiologist because of my blood thinners, they want to make sure if I go off of them 3 days before surgery that I won't get another DVT. Its a pretty tricky situation for me. I had to go off of them before when I had surgery on my wrist..I started to swell up fast.

I'm one of those rare people...whatever rare happens in a procedure its me who will get it..

I'm keeping my fingers crossed for you.

em1125

did you meet with the surgeon that was actually going to do the procedure on you or just his/her assistant?

I met with the surgeon who will be doing the procedure if my insurance approves it. My BMI is 35.3...I gained a whole 1 1/2 pounds before I weighed in..didn't bump me too much...lol

I hope when the surgeon says "You'll be approved" he means it...its crazy to get all excited then have your heart broken. I'm so afraid of that. I was sooo happy after meeting with him. He of course has to work with my cardiologist because of my blood thinners, they want to make sure if I go off of them 3 days before surgery that I won't get another DVT. Its a pretty tricky situation for me. I had to go off of them before when I had surgery on my wrist..I started to swell up fast.

I'm one of those rare people...whatever rare happens in a procedure its me who will get it..

I'm keeping my fingers crossed for you.

I had pulmonary emboli (both lungs) and had to go off Coumadin for the surgery. They gave me lovinox injections 3 days prior to surgery and for 2 days after the surgery and I did fine.

I met with my surgeon individually. Loved him. I chose him because he's a very well known bariatric surgeon in NYC. He has done several celebrities and has been in the media alot in the last few years.

Your BMI is not very high however, you have life-threatening co-morbitities. That alone should get you approved.

You probably mentioned this on one of the previous threads. I don't remember. Why are you on blood thinners? What's wrong with your circulation/heart?

Talk to you soon.

Em

Elizabeth,

That had to be scary for you as well. Thank God you did well. I see you had your surgery done in NY. Are you from NY?

Em

I get DVT rare ones in my upper extremity and superior vena cava syndrome....I've had five angioplasties but no luck getting through my veins..totally occluded. I was on coumadin (20 mgs a day) then I became allergic too it, so I'm back on lovenox, which I hate so much! I have to be on it for the rest of my life.

Wow you have a great surgeon!!!

I hope you get approved after the appeal. You deserve it sooo much!

Keep us all posted.

Hi all,

Just an update. My PCP called my insurance company to see if he could get any feedback. He spoke with the medical director who was ultimately the one who made the final decision on my denial. The medical director told my PCP that the reason he denied me was because I have not had a BMI of 40+ for five years. He also said that my appeal is with someone different and that this person may feel differently. Basically my BMI went from 32 to 39 within the last five years.

I would say looking at this record I'm definetely on a upward slope here. So we'll see. No other info to report. I'm getting very impatient and truly want to have this procedure done asap.

em

There is always the Monterrey option. I've heard only good things about Dr. Roberto Rumbault.

I have been seriously considering Mexico. My family and PCP are totally against the idea of me leaving the country to have this procedure done. I am totally fine with the idea. I have only heard wonderful things about Raumbault.

It's funny, my DH and I have been truly considering this. If I have my surgeon perform the surgery, it will cost anywhere between $23,000 and $25,000 in NYC (which I have already considered paying).

We'll see.

em

I finally was sent the letter approving me today...a FULL YEAR after after I started...three denials later...DONT GIVE UP! Ask your hr rep who your insurance broker is and call them to see if they can help. Mine was a huge help in knowing the ins and outs of the system. I had to send them records three times, and a bunch of other stuff that made me feel it was all to give me the run around. My doc charges 17k to do the suregery and self pay isnt an option, so it was either keep fighting or not have the band..Surgery date of August 9th!

AWESOME! Congrats. I wish you all the best. After 3 denials and all of your hard work, you truly deserve it. I bet the insurance company thought you would eventually quit after a few months. Good for you. You fought for one year and now it paid off.

In the year of fighting with the insurance company, did your weight increase, decrease or remain the same?

I am very happy for you. Hopefully, I should be hearing something soon and maybe I'll be celebrating

em

Okay reading these posts is starting to scare me.....does you insurance not cover it, or it is covered but not you specifically. So far my insurance has paid for all my tests, and they do cover the surgery...if they turn me down at this point i will go insane. (hubby will be relieved, but i won't!!)