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What happens if I am denied? Please help.

Carolyn2167

By Carolyn2167, in Insurance & Financing

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Carolyn2167    4

Carolyn2167
Posted

I’ve been making myself a little crazy and losing sleep worrying, so I’m hoping I can get some of your thoughts on this.

I’ve completed my six months of medically supervised weight loss appointments. I’ve had the sleep study, EGD, psych eval and all of that jazz. I called my doctor last week to ask how long it should take to hear back regarding scheduling my surgery, they said that they have to submit everything to my insurance company and then it will take 2 weeks to hear back after that.

Okay, that’s all good, but then I did a google search for my insurance company, “McClaren” and “Weight Loss Surgery.” And I found a website for a hospital here in Michigan that does weight loss surgery (not one I’m going through, just a random one that my Google search found), they listed requirements of a bunch of different companies, including mine. For my insurance company it says that they require a “Medically Supervised Diet for 6 Consecutive Months. food & Exercise Journal, Showing a consistent weight loss with no weight gain.” Here’s the thing, the last month of my supervised diet, I gained weight. I’m not sure why. I’d had the flu for a couple of weeks that month. I wasn’t eating much, I really expected to lose but didn’t.

So, has anyone ever been denied coverage because they didn’t do well during their MS diet? If so, what happens? Do you have to do it again? The whole six months over again? Is there an appeals process? My insurance coordinator at the doctor’s office isn’t very familiar with my insurance company, in fact she said that this is the first time she’s worked with them. She’d told me that they want to see you “lose a few pounds, here and there.”

I’m totally freaked out about this. Could I have totally blown everything in one bad month? What do you think?

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Amurillo04    109

Amurillo04
Posted

Normally at least for my insurance they are looking to see if there is a net gain. My coordinator told me that as long as by the end of my 6 month I didn't weigh more then I did originally I would be ok.

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Carolyn2167    4

Carolyn2167
Posted

Thank you both. I'll try to chill out. ????

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SleevedAmy    3

SleevedAmy
Posted

I’ve been making myself a little crazy and losing sleep worrying, so I’m hoping I can get some of your thoughts on this.

I’ve completed my six months of medically supervised weight loss appointments. I’ve had the sleep study, EGD, psych eval and all of that jazz. I called my doctor last week to ask how long it should take to hear back regarding scheduling my surgery, they said that they have to submit everything to my insurance company and then it will take 2 weeks to hear back after that.

Okay, that’s all good, but then I did a google search for my insurance company, “McClaren” and “Weight Loss Surgery.” And I found a website for a hospital here in Michigan that does weight loss surgery (not one I’m going through, just a random one that my Google search found), they listed requirements of a bunch of different companies, including mine. For my insurance company it says that they require a “Medically Supervised Diet for 6 Consecutive Months. food & Exercise Journal, Showing a consistent weight loss with no weight gain.” Here’s the thing, the last month of my supervised diet, I gained weight. I’m not sure why. I’d had the flu for a couple of weeks that month. I wasn’t eating much, I really expected to lose but didn’t.

So, has anyone ever been denied coverage because they didn’t do well during their MS diet? If so, what happens? Do you have to do it again? The whole six months over again? Is there an appeals process? My insurance coordinator at the doctor’s office isn’t very familiar with my insurance company, in fact she said that this is the first time she’s worked with them. She’d told me that they want to see you “lose a few pounds, here and there.”

I’m totally freaked out about this. Could I have totally blown everything in one bad month? What do you think?

My insurrance denied my surgery. I went to my states local vocational rehabilitation office. They have a program to help bariatric weight loss surgery. They paid for my surgery. It was affecting my ability to work full time. Check yours out. We are in Kentucky. Hope it helps.

Amy

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Carolyn2167    4

Carolyn2167
Posted

@@SleevedAmy what is the reason that you were denied? Is it because you gained weight during the diet documentation period? If so, was it an overall gain or just one month of gaining?

Thanks!

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SleevedAmy    3

SleevedAmy
Posted

@@Carolyn2167

It is an exclusion from my health insurance policy. That is why it isn't covered. I had to find alternate ways to get my surgery covered.

Amy

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loca_lette813    30

loca_lette813
Posted

@@SleevedAmy what is the reason that you were denied? Is it because you gained weight during the diet documentation period? If so, was it an overall gain or just one month of gaining?

Thanks!

Maybe you could help me.. When i started i was 325, i kinda let myself go and gained 45pounds (370)...BUT i now weigh in at 335....do you think theyll deny me?

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Amurillo04    109

Amurillo04
Posted

@@loca_lette813 it's best to call you specific insurance provider and coordinator for that information as all people are different however for me my insurance would deny me if I gained weight (net) AND my surgeon would deny me as well even if my insurance approved. However if your surgeon and coordinator didn't make it clear that you cannot gain weight you may be ok. Good luck.

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loca_lette813    30

loca_lette813
Posted

@@loca_lette813 it's best to call you specific insurance provider and coordinator for that information as all people are different however for me my insurance would deny me if I gained weight (net) AND my surgeon would deny me as well even if my insurance approved. However if your surgeon and coordinator didn't make it clear that you cannot gain weight you may be ok. Good luck.

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Ill definitely do that, but no one really told me i couldn't gain weight or that i had to lose any

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