OK, sooooooo heres the deal.

I submitted to insurance and got denied because they said it wasnt medically necessary. So I appealed it. I found out yesterday that my appeal got denied. In my appeal letter I had mentioned that I had gained about 5 lbs since my weigh in with my Dr.... so, Im on the phone with my appeals nurse and she tells me that I got denied for not having a high enough BMI, because I dont weigh enough and me just writing in a letter saying that I gained weight isnt valid material (makes sense, no biggie). So I ask her "will it help my case if I go in and have my weight confirmed by my Dr?" she says "well you caaaaan, buuuuut I dont know how much it would help you because we have denied people on the sheer fact that they gained weight and didnt change their lifestyle for this surgery"

DEEP BREATH....

OK. SO. you are telling me that I dont weigh enough for you to cover me, but if I gain any weight you wont cover me either??? ISNT THIS WHOLE PROCESS FOR THE SPECIFIC PURPOSE OF CHANGING MY LIFESTYLE???? IF I COULD DO IT WITHOUT THE VSG, DO YOU THINK I WOULD BE ASKING YOU FOR COVERAGE????????? YOU TOOK 3 MONTHS TO DENY MY CLAIM TWICE AND WONDER HOW ON EARTH I GAINED 5 POUNDS??? LADY! IF I WERE ONLY WORRIED ABOUT 5 POUNDS ID GO TAKE A CRAP AND THEN WEIGH MYSELF AGAIN!

UUUUUUGH!!!!!! any advice on what I can do to get these people to change their minds????

HELP PLEASE!!!:help:

You know, I simply don't understand why insurance companies don't get that if we loose weight and get healthy, they will be paying out a whole lot less in the long run than if we end up with chronic illnesses caused by obesity. My insurance doesn't cover it at all, so I had no choice but to self pay. So to Mexico I go I will loose this weight and I will have a life!!

Lisa

Getting "certified" material from your doctor to your insurance company is going to be your only avenue - unless you elect to go the self pay route. Do you have any co-morbidities? High blood pressure? Diabetes or pre-diabetes? I would NOT keep gaining weight just to qualify.

And I suggest the following reluctantly - think about self pay. I was lucky in that I have insurance but did not want to go through all the crap they make you go through and wait-wait-wait. A woman where I work inspired by my rapid weigh loss started down the insurance path over 6 months ago, she is STILL getting the run around despite the fact she has JUMPED on everything they have asked her, doctors visits, psych eval, you name it - she did it immediately. Then they "lost" her information and she had to resubmit and get the doctors to resubmit it all over again. It is really a racket.

I had the cash, made the contacts and was sleeved in about a month - it would of been sooner but I had to get a renewed passport first. Medical Tourism is not for everyone but it worked for me.

I too have insurance (Kaiser to be exact) and didnt want to deal with their crap so I self paid and went to Dr Ramos Kelly. Much easier than dealing with my insurance. I am thinking about canceling it and saving the $300.00 a month and use ugent care if I get sick. After paying the $300 a month I cant afford the $70. copay.

What is your BMI? & weight?

It's a shame insurance companies treat over weight persons so badly. My insurance doesn't cover ANYTHING that has to do with weightloss. Nothing. But they will cover some one who needs help with their smoking problem. I was stopped cold in my tracks when I started to inquire about WLS. So it became apparent that u have to finally take control of the situation and researched medical tourism. Like the previous post or may not be for everyonr. But I think its worth looking into and coming up with the money seemed like a breeze when I realized how much I'd pay I the U.S. vs. Mexico. Dont get discouraged. If u know this is right for you, then you can make it happen. Good luck and keep us updated.

I too have insurance (Kaiser to be exact) and didnt want to deal with their crap so I self paid and went to Dr Ramos Kelly. Much easier than dealing with my insurance. I am thinking about canceling it and saving the $300.00 a month and use ugent care if I get sick. After paying the $300 a month I cant afford the $70. copay.

Isn't it a mess ?! The thing is you will end up having to pay all the expenses anyway... If Kaiser finds out you had surgery "out of house" they can refuse to pay for any after care you may need concerning any kind of GI problem etc... Say you develop an ulcer 5 years down the road... they won't cover you. That's why I am dealing with Kaisers crap and jumping thru the hoops of fire, otherwise I would self pay.

How did u determine that your iinsurance won't cover any future problems that may result from the vgs? I'm going to be self pay too if I ever get the chance to havge the surgery. Am wrking with major ivy league university hosp. Cost is about 25,000.

I can relate and feel your pain. I too was denied, although by Aetna last month after 7 months of hoops. They denied me based on my lower than required BMI of 40 in 2009 while working out with a trainer and dieting. God forbid you show that you have sincerely tried. This was addressed in a letter beforehand but they ignored it . I am still waiting for my surgeon to do a peer to peer . I meet all other requirements with the exception of the 24 month continuous 40 BMI. I was ok in 2008 and 2011, had no documentation for 2010, but 2009 killed me. Next stop INSURANCE BUREAU!! Don't waste your appeals by yourself. God to your states insurance bureau and get an advocate, it may help. Good luck..

I'm talking @ medicare. There is no way to work with them

I went into this process expecting to be self pay. I do not have any health issues aside from being overweight and I barely met the bmi requirement for surgery. I wanted to stay local and the "package price" at my hospital was $20,000.00. A little tough to stomach paying that much but I was willing. Before I even went to my first seminar at my surgeons office I found out I was denied by insurance. No big surprise there. Then after I had my first one on one with my surgeon she said she was going to submit a letter to my insurance company explaining why I was a good candidate for this procedure to see if I could get coverage. Next came the list of things isurance wanted me to get clearance on before they would consider me for surgery. I did all the tests because if by chance I could get covered for this it was going to save me 20 grand! After the surgeons office got all the info insurance had requested from me they resubmitted and I got approved! I was so shocked. Even the cardiologist I went to (one of my tests was cardiac clearance) told me that I should not expect to be approved. She was a nice lady and told me that in her opinion they were just looking for reason to not cover me. She was wrong! This whole process... from my first call in to inquire about the surgery to surgery date was 3 months. If your surgeon will send a letter to insurance on your behalf you should have them do it. Then jump through the hoops. I was so tempted to not jump through hoops but now I am so happy I did. Good luck to you... I know it is frrustrating but keep pushing to get it done because it is so worth it

I'm working on it since last summer. Out of patience, out of time. Glad for you, though. Are u in the new england area?