:think I got a rejection letter from the insurance today! Can I just say- They stink!!! I actually have some much stronger adjectives to describe them but I will spare all of you the cursing.

Our reviev determined that the denied services(Lap band) requested are NOT MEDICALLY NECESSARY based on the following:

There is no documentation of 12 continuous months of medically supervised weight loss program that includes nutritional therapy, behavior modification, supervised increase in activity, pharmacologic therapy-unless contraindicated-and maintenance support. This 12 month program must have been in the last 24 months. Programs such as weight watchers or Jenny Craig are not considered medically supervised weight-loss programs.

Anyways-I am upset to say the least. I have been through so much to try to get approved. How can they say it's not Med. necessary? With all of my medical problems, I am in the dr.s office atleast 2-3 times a month! Medical equipment for sleep apnea(which is probably due to weight!) Medications for depression, anxiety, migrains, etc...... Don't they understand that if I lose weight-many of these problems will go away?! I have so many thoughts and frustrations going through my head right now! This surgery has been the only source of hope that I have had that I might be able to actually live a normal life. I am trying not to have a "melt down" but I just feel like my rug between hope and hopelessness has just been yanked out from under me! What do I do now?

Be careful about the financing offered through the doctors since the interest rates are pretty high. If you are able to qualify for one of their loans, chances are you can just as easily qualify for a low interest credit card. I got a card that offered 0 percent for the first year. I'm making payments towards it, and at the end of the one year I'll try to get another card with 0 percent for one year and transfer the balance. But if you can't qualify for a low-interest card, the surgery is worth the extra interest in my opinion.

Lauri,

I completely understand where you are coming from. I have BCBS and I had to fight the fight for 2 years and they are still trying to deny after I've had the surgery (on a technical reason of which I have all the documentation for). But I had a very supportive PCP who helped me in getting all the necessary requirements fulfilled. I did take Meridia (and I was on an anit-depressant at the time as well though I don't know about thyroid medications-ask you PCP) and she had at one time or another given me written information regarding my weight and different diets or nutrition plans that she was suggesting. In other words, she did consider that her support and advice and the fact that I, too, was seeing her for one type of medical problem or another was in her opinion a medically supervised weight loss program. The insurance likes to make us work for it and sometimes they like to think that we all just like being overweight. My PCP made the comment tha although she understood that I had a weight problem and was a compulsive eater that it was not like I was trying to make myself fat and the fact that I was addressing the issues with her everytime that I saw her was true evidence that I wanted to be successful but that obviously regular diets were not going to work. I was 32 and had spent over half my life on one kind of diet or another. I needed a little more help and the older I got, even when I lost a little weight, my body could less and less work with the weight it carried.

So just try to hang in there. You have all of our support and talk to your PCP to see what he/she may be able to do move the process along. For me, it was so worth the wait and frustration because I can now see a true light at the end of the tunnel.

Good luck!

Thank you! I am so glad that I have the benefit of the groups experience and support. Don't know what I would do without you.

Well, I made another step. I said that I would work on my appeal after the holidays but I realized that I was REALLY afraid of rejection. I was putting it off! So, I went to see my doctor and told her about the rejection. She was upset for me. She said she just doesn't understand why insurance would refuse anyone a surgery that will really help them. We talked about how EVERY time I have been into the office for the past 3 years-I have talked about my concerns over my weight and my frustrations.

She is going to write a letter to the insurance company. Now, I am going to work on writing one of my own(any suggestions as to some things that I might include in that letter?). The nurse in my doctors office that has a band-told me to write the letter, make copies(so that I can resend it often), and call the insurance company and wear them down if need be.

So-another tiny step is taken in my journey. I feel proud of my self. I am trying to face my fears and fight for me. It's interesting how many of us do not/did not take care of ourselves. For as long as I can remember, I would buy my family nice clothes, give them their Vitamins, feed them their veggies, limit their consumption of sugar and caffine, talk sweetly to them, and offer words of encouragment to assure that they are healthy, happy, and have positive self images. While in the mean time, I refuse to buy myself the clothes I need because I should lose weight first, grab fast food when I am out running errands, drink way too much coke to "try" to give myself enough energy to do the things I need to do, and verbally abuse myself! Why is that? But more importantly, will I ever really be able to be kind to me without feeling guilty?

Well, I sure didn't mean to go on like that! I'm stopping now before I get started again!

Good for you Laurie! I really can't give you any advice on the letter as I didn't go through insurance. I just wanted to say I am proud of you for not giving up! I'll keep my fingers and toes crossed for you!

Lauri, I'm really busy right now, but I'd be happy to write a testimonial based on my own experience when I have a minute (I won't include my complications.) Maybe if a few people gave you letters showing that we are no longer dying.... how can they say no? My sleep apnea is gone, my blood pressure within normal range, lower cholesterol, etc.

Thank you Lisa. I think that is a great idea! If you are willing to do that I would definately send it to them.

I have been working on my letter all day and would like to run it by you guys and get some feedback.

(Sorry it's kind of long. I got sort of carried away)

Dear Medical Review Department:

Recently, you sent me a letter denying me weight loss surgery. I would like for you to reconsider this important decision. My life is literally in your hands.

My name is Lauri J. I am Thirty-five years old and I am morbidly obese. From the age of eight, I have struggled with my weight. Honestly, I can not remember a day when my weight was not the first thing on my mind when I woke up and the last thing I thought about before I went to sleep at night. It has effected every aspect of my life for many years. When I was young, my main concern was how I looked and what others thought of me but now, I am extremely concerned about my diminishing health. I’m sure you are aware that the risk of death and serious health problems increase with excessive weight.

Obesity is a major risk factor for serious medical conditions such as:

• Type 2 diabetes

• Hypertension

• Heart Disease

• Stroke

• Sleep Apnea

• Respiratory problems

• Cancer

• Osteoarthritis

• Joint pain

Dr. Cribbons at Plano Medical Center calculated my BMI at 43.8. This places me in the Morbid Obesity category which represents individuals who carry the largest and most dangerous amount of excess body weight.

Morbid obesity is a chronic condition that is difficult to treat through diet and exercise alone. According to the National Institutes of Health, Morbid Obesity Surgery is the best option for people who are morbidly obese and cannot lose weight by traditional means or who suffer from serious obesity-related health problems.

My medical records show extensive health problems. I suffer from sleep apnea and must sleep with a c-pap every night. Obstructive sleep apnea is resolved or improved in almost 84 percent of patients according to an article in an October, 2004 issue of The Journal of the American Medical Association.

I have pain in my knees, hips and back because of the extra weight that I am carrying. This affects my ability to exercise, play with and take care of my children, have sex with my husband, get in and out of my car, clean house, and many other activities. Just moving from one place to another often causes me shortness of breath or fatigue.

Because of my health, I have lost my teaching job. This is causing my family extreme financial difficulties. I have applied to several school districts and been called for interviews on a few occasions. The phone calls from principals go great and they are eager to meet me but, when I walk into the office, things change. As much as it hurts, I understand how they feel. If I had to make the choice between two individuals with similar qualifications but one was thin and probably healthy or a very fat person who might have high blood pressure, heart problems, or who knows what, I would more than likely hire the thin individual. Not to mention the fact that people who do not have weight problems very often think that because you are fat you must be lazy. I don’t blame these individuals. Our society stereotypes fat people. They are often the target for cruel jokes and ridicule.

The many insults, rude comments and attitudes, and general societal disgust with fat people coupled with everything else I have experienced has caused me to avoid social and many other situations where I might come in contact with people I do not know. I become very anxious just thinking about meeting new people. I have never met any of my husband’s friends or work associates because I do not want them to think bad of him for having a fat wife. There are many times that I don’t go to my children’s school parties, field trips, or other activities because I just can’t face people and their attitudes toward me anymore.

Depression, low self-esteem, societal rejection and prejudice, lesser work and income

opportunities, marital, familial, social and sexual problems add to the burden brought on by my weight. The National Heart, Lung and Blood Institute define obesity as a complex, multifactor disease that develops from the interaction between genotype and the environment. Obesity is not just a cosmetic consideration; it was been classified as a chronic disease in 1985.

The National Institutes of Health report that 90% of the people who participate in diets and weight-loss programs do not lose or sustain a significant amount of weight. They suggest that morbidly obese individuals may want to strongly consider weight-loss surgery when other therapies have failed. I have spent countless amounts of time and money in diets and low-calorie/low carbohydrate foods and drinks, exercise programs and other weight loss treatments which, even if successful, only offered me temporary relief. I need this surgery. Studies have shown that weight-loss surgery provides the longest period of sustained weight loss in patients who have failed with other attempts.

For many years, I have watched my mother (who is, also, morbidly obese) suffer physically and emotionally. She has been disabled since her forties. She has had both of her knees replaced, suffers from high blood pressure, and extreme depression. Now, her hips need to be replaced. I need help before irreversible damage is done to my body.

I am a mother of four beautiful children. I have already missed out on so much of their lives because of this extra weight that I carry around. They want their mother to be able to play on the floor with them and go to the park. They need me healthy and strong so that I can care for them. I want to live long enough to see my children grow up. I need to be able to provide for them. How can I teach them to be productive members of society when I can’t even get a job. Who will pay for them to go to the doctor, or to college for that matter?

I do not want to waste one more day of my life. I want to live. This weight has such a negative impact on the quality of my life and is shortening the quantity of my life with each passing day. You can help me live longer. You must see, as my doctors and therapists do, that this surgery is very necessary for my survival.

Great letter, Lauri!!!

You're such a trooper and I am so proud of you!!! With your great attitude and tenacity you are sure to win this fight. Go, girl!!!

Thank you Blossom! Is there anything I should take out/add? I want it to be just right. Honestly, I didn't even know how to start or what to say.

Laurie, I think it sounds great, but I am definitely no insurance expert. You may want to pm Alexandra and ask her to take a look???

Go Lauri go! Great letter. Just a couple of suggestions:

1. Make sure you put in clear breaks between the paragraphs to make it easier to read.

2. Include a history of your attempts at weight loss to show the insurance company that you have tried other ways to lose weight. Some people seem to think the band is an easy way out, and that we're a bunch of gluttonous slobs who lack self-discipline. Emphasize the positive things you have done over the years.

3. Mention any other health problems you have (besides sleep apnea) that will be improved with the band.

4. Consider cutting the section from "As much as it hurts" through "burden brought on by my weight." It is all true, but might overload the letter.

I'm one of the impatient bandsters who couldn't wait for all the insurance nonsense, so I got a home equity loan. Three months later, I have a new kitchen and a band. If you own your home, this is another option you might consider in case the insurance company won't budge.

Give yourself a big banana dance :banana for having the guts to fight this battle! You are brave! You can do it! Let us know what happens next.

Lauri,

That is a great letter. I hope those insurance people wise up and give you what you need. It's a joke how these people make us jump through hoops to be taken care of. Of course, they don't think that down the road, they will ahve to pay to treat all those comormibities (spelling?) .

Good luck!!

Sonia

Thank you all for taking the time to read the letter. I appreciate the in-put.

Zoe-the actual letter has appropriate spacing and a professional heading. I still need to work on the grammer and structure some though. But for some reason when I cut and pasted it-it changed some????? Who knows? Computers are weird!