denied.......feel like I got gut punched

[doggz109 41]

So I finally got my letter back from HealthNet today. They denied the request for surgery and basically said they would need more information - specifically regarding "any history of anemia, inflammatory bowel disease, Chron's disease, surgery history, celiac disease, ulcerative colitis, and medication history (specifically anti imflammatories).

I guess this is not a flat out denial but I'm still sort of in shock. I have a 54 BMI, gout, high blood pressure, arthritis and have been overweight/obese since I was about eight years old. I know I'm not as bad off as some people....but I thought I was pretty much a poster child for who should get this surgery. The surgeon and coordinator at his office both said I was a total shoe in and that they haven't had any problems with Health Net. It's definitely covered and I made sure that my employer did not have an exclusion for it.

So any ideas on what to do next? I'm not sure how the appeal process works and I haven't had any of the bowel issues (Chron's, celiac, IBS, etc) that they are mentioning. The only thing close is Gout and I have to occaisonally take some strong NSAIDS when that flares up (like Indocin).

Thanks for any ideas.

[wishes 125]

Oh wow, I am so sorry. I hope you fight this. Good luck!

[groovearmada 14]

Sorry i cant help (was self-pay) just wanted to say im really sorry. Cant believe they denied, even with a BMI of 54.That alone should be enough. Not fair. Fight them! I hope some others can help.

xxx

[meggiep 57]

This makes no sense. Most insurance companies don;t even require co-morbidities with a BMI of 40 or above so WTF! And I would thing the NSAID would count against you having it- maybe they just want to make sure.

FIGHT FOR IT!

[Beadingnurse 116]

Dogg...consider calling your insurance company yourself....get the name and phone number of the insurance case manager from your coordinator at the doctor's office. A person to person conversation might help so you can explain that while these bowel issues are part of your medical history, they are not active and are not causing you problems now. I used to work in case management for an insurance company and part of what I did was pre-authorizations for surgeries and other procedures. I KNOW that it made a difference when I spoke with the patient versus a coordinator in the doctor's office who may or may not be presenting your case in the best possible way. Be pleasant and friendly but persistent and ask for a medical re-review. I don't know about HealthNet but I know if a patient requested a re-review we were required to go up another level (to the medical director usually) and look at the case again. Remind him/her of what your BMI is, how much work you have done to prepare for this surgery and how you expect the results to positively affect your health.

Good luck....let this be just be a rock in the road and not a roadblock!

[Rootman 1,101]

Yep, what Beadingnurse sed: jump on this like a chicken on a june bug - well she didn't say that exactly but she meant it. If you really want this then PURSUE IT with all diligence. Call them, write them, supply them with every shred of documentation and testimony you can. Keep after them, they are for the most part just bureaucrats and you are just another number - put a face and voice to the number and force them to realize you are a real person and no just a number and need a better answer than what they've given you already.

If possible you may also consider self pay, perhaps in Mexico. Not everyones cup of tea but it worked for me.

We all wish you the best. Go Get 'Em Tiger!

[juliarh 35]

Dogg, so sorry this has happened -- but really do what Beadingnurse says to do -- I've seen lots of people here get an initial "denial" only to appeal it and get it approved. So I'm crossing my fingers and toes for you!

[thinoneday 445]

So I finally got my letter back from HealthNet today. They denied the request for surgery and basically said they would need more information - specifically regarding "any history of anemia, inflammatory bowel disease, Chron's disease, surgery history, celiac disease, ulcerative colitis, and medication history (specifically anti imflammatories).

I guess this is not a flat out denial but I'm still sort of in shock. I have a 54 BMI, gout, high blood pressure, arthritis and have been overweight/obese since I was about eight years old. I know I'm not as bad off as some people....but I thought I was pretty much a poster child for who should get this surgery. The surgeon and coordinator at his office both said I was a total shoe in and that they haven't had any problems with Health Net. It's definitely covered and I made sure that my employer did not have an exclusion for it.

So any ideas on what to do next? I'm not sure how the appeal process works and I haven't had any of the bowel issues (Chron's, celiac, IBS, etc) that they are mentioning. The only thing close is Gout and I have to occaisonally take some strong NSAIDS when that flares up (like Indocin).

Thanks for any ideas.

Well, I took out a loan. . . yes it's the price of a small new car, but it's worth the money. . . best investment I ever did. . . good luck!

[Dansha 16]

Soooo sorry Dogg. I don't understand HOW THEY CAN DENY YOU!!! Fight it bro. Please keep us posted with any updates. GOOD LUCK!!!!!!!!

Deb

[Beadingnurse 116]

Yep, what Beadingnurse sed: jump on this like a chicken on a june bug - well she didn't say that exactly but she meant it. If you really want this then PURSUE IT with all diligence. Call them, write them, supply them with every shred of documentation and testimony you can. Keep after them, they are for the most part just bureaucrats and you are just another number - put a face and voice to the number and force them to realize you are a real person and no just a number and need a better answer than what they've given you already.

If possible you may also consider self pay, perhaps in Mexico. Not everyones cup of tea but it worked for me.

We all wish you the best. Go Get 'Em Tiger!

I ABSOLUTELY meant to say Dogg should jump on this like a chicken on a june bug! Glad you read between the lines!

[feedyoureye 3,087]

So I finally got my letter back from HealthNet today. They denied the request for surgery and basically said they would need more information - specifically regarding "any history of anemia, inflammatory bowel disease, Chron's disease, surgery history, celiac disease, ulcerative colitis, and medication history (specifically anti imflammatories).

I guess this is not a flat out denial but I'm still sort of in shock. I have a 54 BMI, gout, high blood pressure, arthritis and have been overweight/obese since I was about eight years old. I know I'm not as bad off as some people....but I thought I was pretty much a poster child for who should get this surgery. The surgeon and coordinator at his office both said I was a total shoe in and that they haven't had any problems with Health Net. It's definitely covered and I made sure that my employer did not have an exclusion for it.

So any ideas on what to do next? I'm not sure how the appeal process works and I haven't had any of the bowel issues (Chron's, celiac, IBS, etc) that they are mentioning. The only thing close is Gout and I have to occaisonally take some strong NSAIDS when that flares up (like Indocin).

Thanks for any ideas.

This sounds to me like they are questioning the sleeve, not the surgery. Those are a list of problems that are best matched with the sleeve instead of bypass... My sleeve was approved partly because I need to take aspirin every day per my Cardiologist... They may think that bypass will give you better results than the sleeve and are trying to find out if there are specific reasons to approve the sleeve.

[Valentina 2,642]

In all my years (way more than I want to admit) as a medical office admininstrator I can tell you what works best by far is a PEER TO PEER consult. Your doctor needs to get on the phone and convince the insurance co. doctor just why it is upmost important to your well being to have this surgery. That will work if your doctor is any good at "articulate and assertive converstaion--which most are!

All is not lost!!! Be assertive yourself when convincing your doctor to do this. IT WORKS!!!!!!!!!!!!!!!!

GO FOR IT!!!! NOW IS NOT THE TIME TO BE SHY!!!!

Keep in touch.

Valentina

So I finally got my letter back from HealthNet today. They denied the request for surgery and basically said they would need more information - specifically regarding "any history of anemia, inflammatory bowel disease, Chron's disease, surgery history, celiac disease, ulcerative colitis, and medication history (specifically anti imflammatories).

I guess this is not a flat out denial but I'm still sort of in shock. I have a 54 BMI, gout, high blood pressure, arthritis and have been overweight/obese since I was about eight years old. I know I'm not as bad off as some people....but I thought I was pretty much a poster child for who should get this surgery. The surgeon and coordinator at his office both said I was a total shoe in and that they haven't had any problems with Health Net. It's definitely covered and I made sure that my employer did not have an exclusion for it.

So any ideas on what to do next? I'm not sure how the appeal process works and I haven't had any of the bowel issues (Chron's, celiac, IBS, etc) that they are mentioning. The only thing close is Gout and I have to occaisonally take some strong NSAIDS when that flares up (like Indocin).

Thanks for any ideas.

[christiemon 20]

I hear a lot of insurance companies deny initially if they do not receive all the information required for the submission. I was getting truly frustrated with my surgeons office when they were taking so long to submit my paperwork. Right off the bat with my first consult my surgeons office had told me that my insurance would deny me if we didn't have absolutely all info required which wound up being about 50 pages of medical history, notes, etc. In the end - I think it helped me get my approval the first time. So maybe they didn't submit everything your insurance company required. I would absolutely think that you have a great chance with an appeal. Good luck to you. = )

[weho 103]

Dogg, it sounds like you have gotten some really good advice here. I'll say a prayer for you! Don't give up, fight the good fight.

[mnbsleeve 87]

Hi Dogg,

I don't really have any advice since I'm self pay (surgery scheduled June 6th), but I like what people are saying here. I've read lots of posts where people are initially denied but then everything comes through. So don't loose hope!!!! Stay with it and just think of it as just another hoop you need to jump. You can do it!!!!

So I finally got my letter back from HealthNet today. They denied the request for surgery and basically said they would need more information - specifically regarding "any history of anemia, inflammatory bowel disease, Chron's disease, surgery history, celiac disease, ulcerative colitis, and medication history (specifically anti imflammatories).

I guess this is not a flat out denial but I'm still sort of in shock. I have a 54 BMI, gout, high blood pressure, arthritis and have been overweight/obese since I was about eight years old. I know I'm not as bad off as some people....but I thought I was pretty much a poster child for who should get this surgery. The surgeon and coordinator at his office both said I was a total shoe in and that they haven't had any problems with Health Net. It's definitely covered and I made sure that my employer did not have an exclusion for it.

So any ideas on what to do next? I'm not sure how the appeal process works and I haven't had any of the bowel issues (Chron's, celiac, IBS, etc) that they are mentioning. The only thing close is Gout and I have to occaisonally take some strong NSAIDS when that flares up (like Indocin).

Thanks for any ideas.