Denied!!!

[seanmama 0]

Hello everyone,

I have waited for a couple of days to post as I have been overwhelmed with hopelessness and anger. I recd my denial letter from United Healthcare in the mail on Thursday evening.

Of course this came as a shock as I was completely pursuaded that uhc would pay- I am a nurse and we do lots of bariatric surgery at my hospital- frequently pts that are around my weight with the same insurance. So of course, that, combined with most everyone conveying the attitude of " oh you have uhc, no problem, lucky you"- had me in a fools paradise. I never doubted for a second that it would be covered.

The reason is that my plan only covers "wls for the morbidly obese" and although I am severely obese, with 100lb + to lose and at least 3 comorbidities, they are sticking to the rules.

Can some one please help? I know I am not the only one who has been here. I feel so hopeless and frustrated. I have already tried to contact all the drs I have seen in the past 10 years or so to get my medical records, so that I can offer proof of comorbidity. Unfortunately I have only done 2 medically supervised wt loss attempts and don't even know if one of those companies (LINDORA wt Loss clinic, Glendale/Pasadena, Ca ???) still exists.

And as for pursuading my husband to go for the Mexico option.....That was met with contempt and a flat NO! His advice was- go on the exercise bike every day and you will lose 2 lb a month. can y'all imagine how that made me feel? That would only take me 50 months right, lets see, thats about 4 years. Boy I can see my resolve lasting that long. LOL.

Thanks for allowing me to vent!

:think :cry

[lmtorb 3]

Seanmama,

So sorry you're having trouble with UHC!! Is your BMI high enough to categorize you "morbidly" obese, or are you in the bracket just below that? Reason I ask is that you said you have 100+ pounds to lose with 3 co-morbidities. I also have 100+ to lose with 2 co-morbidities (high bp, sleep apnea) and got approved. But my BMI put me in the morbidly obese range, and maybe that's what did it. Have you tried having a different doctor write up a letter for you stating it is a medical necessity? I've read a LOT of posts here from people who fought for a LONG time with insurance companies but eventually won. I'd sure give another doctor a shot at writing that important letter for you! I believe Alexandra, who posts a lot here and helps A LOT, had to go through this, too. Maybe she can be of help?? Hang in there and do NOT give up at the first denial!!!

[Alexandra 55]

Hey seanmama, don't give up!!!

The reason is that my plan only covers "wls for the morbidly obese" and although I am severely obese, with 100lb + to lose and at least 3 comorbidities, they are sticking to the rules.

So what is their definition of "morbidly obese"? If you have 100 lbs to lose your BMI must be pretty close to 40, right? Try shaving an inch off your height and see what that does to your BMI. UHC probably uses the same definition as everyone else, and if you are borderline you might have to try a little harder to make the case.

This sounds like a matter of your doctor not having sufficiently explained your health issues to UHC. You should get a copy of your file from your doctor's office and make sure it includes everything you think is appropriate. Then send in your appeal focusing in on the fact that you DO fit their medical criteria and should therefore be approved.

All is not lost, not by a long shot. You're in much better shoes than someone with a policy exclusion or an "investigational" denial. Don't worry--just keep at it!

[seanmama 0]

Thankyou Larry and Alexandra,

According to my denial letter, " the enrollee does not meet the definition of morbid obesity, lacking significant comorbidities".

I have diagnosed arthritis and GERD, painful joints, snore at night to the point that my husband has slept in our study since my third pregnancy 5 years ago(!!!!) and am hovering at the uppermost limit of normal BP. My sugar is normal- thank the lord- at least for now! The list goes on and on.

Alexandra, I have to think maybe the dr's letter was not very persuasive. Do you think I should try another Dr here in the Dallas area? I don't know of any others that do lap banding. Or should I try to convince my primary care MD?

As for my BMI, it is 38. I am 5'4 (that is about as short as I can hunch up ) and weigh 222lb give or take 5lb depending on the time of month.

[marsha 0]

Seanmama,

You and I have almost the same circumstances! Your story makes me depressed as well. I'm waiting for insurance approval also. I have United Healthcare PPO and was also told by my doctor that I shouldn't have no problem getting approval. My BMI is only 36! I have GERD, Osteoarthritis, stress incontinence and am a borderline diabetic (controlled with diet). I'm going for a sleep study in 2 weeks to check for sleep apnea! Now, I'm afarid I wont be approved either!! My husband is totally against going to Mexico and he also thinks I should just "go on a diet and exercise". I know I could loose a few pounds in the short term but I also know I'd just gain it back along with a bonus 10 pounds for putting in an effort! :think

Have you thought about getting a lawyer? There is a guy on the web that specifically helps with insurance for bariatric surgery...I think the web site is www.obesitylaw.com and he is reasonably priced for an attourney. Others on this site might have more info on him. DON'T GIVE UP!!!

Good Luck and PLEASE Keep us informed. You can email me anytime!

Marsha

[GeezerSue 7]

Sometimes, it's semantics...

They say you lack "significant comorbidities." They need to define "significant comorbidities."

It is likely you have one or more and just haven't yet had them diagnosed. For example, you say you snore. Nice info, but not a "significant comorbidity." HOWEVER, obesity-related sleep apnea may be a "significant comorbidity" as defined in their regulations.

So, 1) find out how they define "significant comorbidity;" and, 2) find out if you have neglected to have one of those problems diagnosed and presented to them?

ALSO, do not assume that you will lose 100 pounds in less than 50 months with the band! The average wls surgery patient DOES NOT lose 100% of his/her excess weight. The average patient loses about 65-70% of the excess weight, in about two years! So, two years post-op, the average wls patient with 100 pounds to lose will have lost about 70 pounds. Half the patients will lose more than that, and half will lose less. We often are so anxious to do something that we forget the average and that half of patients lose less than the average. Besides, you need to do the bike or treadmill or some exercise anyway.

Sue

[seanmama 0]

Thanks to all for taking the time to reply to me. I feel like i need to respond- esp to Sue.

Yes, I am fully aware that wls is not a magic bullet and that it still takes PLENTY of effort and dedication. However, truth be told, I would be perfectly happy to lose 50-80lb. AND KEEP IT OFF!!!!.......with the HELP of the band. Over the course of the last 20 years I have lost and regained probably 10 times that amount.

Believe me, I may have "only around 100lb" to lose, but that is as much of a mountain to me as it is for say someone who has 150, or 200lb to lose. I can EASILY get to that point (I am not even presently at my highest weight)- in fact it has taken a huge effort NOT to gain way more than I alredy have.

I plan to gather up my med records and send proof of diagnosis with my appeal. And I plan on having a sleep study done for the possible sleep apnea. Your suggestion to get their definition for "significant comorbidities" is excellent.

As far as the legal option- I may go there if my first appeal is denied- hopefully it won't be.

[lmtorb 3]

Seanmama,

I had my band done by Dr. Adam Smith, D.O. His office is in Fort Worth right across from the Osteopathic Hospital. You might try calling him (he's listed in the phone book) and see if maybe they can help you. There is also a doctor in Decatur, Dr. Snow, who does LapBand surgery. Don't give up!! If you need more info on Dr. Smith, please feel free to send me a personal message and I'll respond and help as best I can.

[Alexandra 55]

Alexandra, I have to think maybe the dr's letter was not very persuasive. Do you think I should try another Dr here in the Dallas area? I don't know of any others that do lap banding. Or should I try to convince my primary care MD?

IMO, trying again with the same doctor will get you farther with your carrier than trying for the same thing with another doctor. See, the insurance carrier is insisting that it's YOU who do not meet their medical criteria--they're not going to change their minds about that if you have a different physician. But you can absolutely ask your doctor for a copy of the letter he sent, get that sleep apnea test and add those results, have your PCP write another letter, and so on.

UHC MUST look at any information you want to add to your current file, and IMO it makes a stronger case if your position on appeal is that they didn't get a complete set of facts the first time. Going to a different doctor just makes it look as though you don't trust the first one, or that you somehow think it was *his* fault you don't meet UHC's criteria.

Try to look at it from their point of view. You already know they approve this procedure for medically qualified individuals. You either are one, or you aren't. Who your doctor is doesn't matter. What does matter is how persuasively you can put together the facts to support the medical necessity of the procedure according to UHC's criteria. Don't leave this up to your doctor alone! You are the patient, and you can include whatever information you want in your appeal package.

[seanmama 0]

Thankyou guys- I am encouraged. I have found some excellent examples of appeal letters on the web and will adjust and edit one to fit me:D .

the reason I chose the doc I have is because he practises at my hospital and I know him well. I trust him explicitly, it is just that I have found his staff to be unhelpful. They have told me that because of the new HIPPA regulations they can't help with the appeal- not even suggestions. Oh well, I will give it my best shot- on my own.

On a lighter note- remember I am the postie who'''s husand blabbed to my father in law about my intent to have surgery? Well of course he had to be kept updated, so yesterday DH apparently told him that since I was denied, i won't (yeah, right) be having the wls. SOOOO, in his wisdom he asked Jeff to share with me his life long WEIGHT LOSS SECRET.....SLOW DOWN WHEN YOU CHEW!!!

don't you love it!:banana

[Alexandra 55]

They have told me that because of the new HIPPA regulations they can't help with the appeal- not even suggestions. Oh well, I will give it my best shot- on my own.

Just for the record, that is absolute hogwash. There may be an office policy on their end about helping patients with appeals, but it's absurd to blame that on HIPAA. All the new regulations mean are that no one can have access to your personal medical information without your express permission. That usually means written permission, but you can grant such permission to anyone: your doctor's nurse, your husband, your postman, your dog.

Oh, and yeah: thank your FIL for me.. that's news!

[GeezerSue 7]

Seanmamma...

You wrote: "Yes, I am fully aware that wls is not a magic bullet and that it still takes PLENTY of effort and dedication. "

I didn't think you were under the impression that wls is a magic bullet. I'm just mentioning the math. Statistically speaking, if you take two patients who need to lose 100 pounds and one of them does, the other will lose 40. WHY the second patient loses only forty pounds could be debated forever, probably.

I'll bet that almost no one who is 100 pound overweight wants to undergo surgery for forty pounds; and as as self-pay, I can tell you that $250/lb. does not sound like a bargain to me. I'm just a post-op who is mentioning the odds to a pre-op.

Good luck...

[seanmama 0]

Sue,

Your comments are well taken and yes it is rather eye opening to view it like this. I am somewhat focused on preventing the regain of wt as, just like so many others I am unable for whatever reason to keep wt off once it is "lost". I believe that with the assistance of the band it will be possible.

If I am wrong, please, tell me, anyone.....

[mkcarpen 0]

I have United Healthcare PPO and have been approved for WLS. My surgery is scheduled for 9/15. My BMI is 37 and I have around 75-80 lbs to lose. My cholestrol is slightly above normal and I was supposed to get tested for sleep Apnea.

DON'T GIVE UP!

[helpyourself 0]

Hi,

I was technically not fat enough for lap band. I'm 5'10", and for most of my life weighed 160 or less. Then after a broken love affair, I ate myself to 202. No, I wasnt' 100 pounds overweight, but could not lose more than 8 pounds. Go to Mexico...the doctors don't have their heads up their asses. I highly recommend Dr. Roldlofo Sanchez Rodriguez in Monterry Mexico. He's done thousands and is highly professional. The procedure is done in a state of the art hospital, and cost me $9000 including airfare from Texas. I'm down to 173 from a start weight of 190 pounds, got banded in august 2006.and it is great. HIs email is rsanchezmd@bandingcentral.com

Good luck!

Hello everyone,

I have waited for a couple of days to post as I have been overwhelmed with hopelessness and anger. I recd my denial letter from United Healthcare in the mail on Thursday evening.

Of course this came as a shock as I was completely pursuaded that uhc would pay- I am a nurse and we do lots of bariatric surgery at my hospital- frequently pts that are around my weight with the same insurance. So of course, that, combined with most everyone conveying the attitude of " oh you have uhc, no problem, lucky you"- had me in a fools paradise. I never doubted for a second that it would be covered.

The reason is that my plan only covers "wls for the morbidly obese" and although I am severely obese, with 100lb + to lose and at least 3 comorbidities, they are sticking to the rules.

Can some one please help? I know I am not the only one who has been here. I feel so hopeless and frustrated. I have already tried to contact all the drs I have seen in the past 10 years or so to get my medical records, so that I can offer proof of comorbidity. Unfortunately I have only done 2 medically supervised wt loss attempts and don't even know if one of those companies (LINDORA wt Loss clinic, Glendale/Pasadena, Ca ???) still exists.

And as for pursuading my husband to go for the Mexico option.....That was met with contempt and a flat NO! His advice was- go on the exercise bike every day and you will lose 2 lb a month. can y'all imagine how that made me feel? That would only take me 50 months right, lets see, thats about 4 years. Boy I can see my resolve lasting that long. LOL.

Thanks for allowing me to vent!

:think :cry