Insurance Woes

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I have been trying to get approval from my insurance company since October 2004. They finally determined that there was insufficient documentation presented showing where I'd been on a 6-month doctor supervised weight loss program. To make a long story short, I have had numerous medical problems over the past 2-3 years, which include hypothyroidism, fibromyalgia, gerd, sleep apnea, etc. The symptoms have all worsened in the past year. I have letters of recommendation from an internal medicine MD, rheumatologist, pulmonologist, and endocrinologist. I've had accidents caused by sleep apnea where I fell asleep at the wheel, can't get out of bed a lot of mornings and am in excruciating pain from the fibro. I'm currently taking 9 different medications (some 2-3 times) daily and the doctor/hospital bills keep piling up but they want to harp about a 6-month doctor supervised weight loss program! I've submitted an appeal and am awaiting their response but I was given news a couple of weeks ago that our insurance will be changing effective July 1. Now what? Do I let them know up front that I've been battling approval? Will they consider this pre-existing? Has anyone had this or something similar happen to them? I'm just devastated! I keep hoping that I'll get approval before the change and the doctors can rush me in.... who am I kidding? Do you really think they'll consider approving an operation of such knowing that they'll be dropping us in another couple of months? I need support here.........

Current weight 348; goal - way below 300!

[Alexandra 55]

Hi Tammy,

The good news is that if your company changes from one insurer to another and there are no lapses in coverage, nothing can be excluded as a pre-existing condition. So you don't have to worry about that. And your current carrier can't make decisions based on whether they will have your business in the next year or not. The medical department has nothing to do with the sales department anyway, and one hand won't have any idea what the other hand is doing. In any event, it sounds like you're close to an approval and once you get it, surgery is usually scheduled pretty quickly. The bad news is that if you don't get this handled by your current carrier, you will have to start all over again with a new one.

At this point, what you should do is stay on top of your carrier and make sure they have all the documentation they need. If you appealed without adding any new information to your case they'll probably come back with the same denial. The new information you can add is a letter from your internist detailing your concern and attempts to control your weight over the last six months, which can be written up in such a way as to meet the requirement. But it sounds like he may have already done that?

Don't worry, but don't let more than a couple of weeks go by befor calling your carrier again for a progress report. You should always have an answer to a precert request or an appeal within 30 days, and it's usually faster than that. It would be great if you didn't have to start all over again with a new carrier.

Good luck, and let us know how it goes!

[Guest terrie67]

Tammy, I agree with Alexandra up to a certain point. If you dont get this approved by your current carrier you may have an issue with your next insurance provider if they dont cover the lap band proceedure. I have Great-West PPO and they cover this proceedure however I found out that Blue Cross Blue Shield does not (at least not in the DC Metro area). Just to be sure, find out if the new plan provider covers the lap-band. Make a cold call to the insurance provider and ask (it couldn't hurt). I wish you all the best with this process.

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Thanks guys! I talked to the head of our HR Dept today and she urged me to keep pushing for approval. She said that they haven't decided on a new provider yet but will definitely have one in place before the July 1 deadline. I asked several questions regarding the changeover and she specified that nothing could be considered pre-existing (as you said earlier, Alexandra) because I have proof of prior coverage for the past 18 months. She said that "if" I get approval by the current provider but can't get the surgery scheduled before the change, the new company has to cover the surgery, no questions asked. She also mentioned that with the letters that have been provided by all four of the doctors involved, along with the information in my medical files showing that this is a medical necessity, will qualify me for the surgery even if the policy excludes coverage of weight loss treatment. She said she'd seen cases where legal systems had to get involved but if the doctors state that this is a life or death situation, she was sure it would be approved somewhere down the line. I just have to have patience and keep trying. Now, I'm no expert on the subject so I don't have a clue but it does make me feel a little bit better since I talked to her. It means more to me though that you guys responded so quickly. I've been a member of this forum for about 7 months now and have read alot of great messages from people. I love the idea that people can share their experiences with those of us who are just starting out. It makes it alot easier to deal with the stress when you know that so many people have been through the same ordeal and that the sun's shining brighter on the other side...

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More news! I heard from my primary physician yesterday that the appeals dept from my insurance group had called and they've requested a psyciatric evaluation. She said that once they receive the reports back from that, she sees no reason why I shouldn't be approved! I called the Weight Management Group and they have me set up for my psyc eval Monday!!! YYYYYEEEEEEAAAAAAHHHHH! What's the next step after that?