hm734

I am hoping someone will have a little extra time to help me with a compelling letter to my insurance company. I will try and give you a little back story to help explain what this is for. I have been working with my husbands Union Health benefits office for 2 years to get bariatric surgery. They have been very nice, but their plan is somewhat of a PITA as they require 6 months of medically supervised weight loss PLUS a 12 month maintenance period before they cover any visits (consults or otherwise) for WLS. I completed everything and was given the green light. I went to my consult, NUT, in for my single psych eval and submitted all my documentation....Long story short, my Husbands Union uses a third party for bariatric approval and they requested MUCH more testing, more recent documented weight loss attempts, 6 total NUT visits (self paid), 6 psych exams (self paid again), and all kinds of other weird stuff usually done in your pre-ops. After spending much of that day on the phone, the Union has agreed that they would go by my explanation of benefits, and all I needed was a new physical and updated labs. I will be submitting these tomorrow, however I wanted to include a compelling letter, and quite frankly I am not good at this. Is there anyone here that is good at this kind of thing? I wanted to highlight my co-morbidities and the fact that I am NOT having this surgery for appearance reasons. I am SICK of being SICK. The doctor I saw today (not my usual doctor because he was booked until Sept for well visits) told me that I would be dead by the time I was 50 if I did not get some help. He said he has never seen anyone as small as me have so many health problems (uh, thanks?) See...I ramble! I need some help writing a short and very sweet letter. Because my first submit was closed instead of denied, I want to get approval and move on with my life without having to appeal. My current weight is 209.5 pounds and I am 5' 3”. This makes my BMI 37.1. My health issues include: Hypertension (despite being treated with Metoprolol) Crainal Hypertension (causing severe headaches) Metabolic syndrome High Cholesterol (despite being treated with Niacin 500mg daily) Pre-Diabetic (being controlled by Metformin 750mg two times per day) Urinary stress incontinence (requiring use of a pantyliner all the time, and maxi pad at night) Polycystic Ovarian Syndrome (despite being treatment of Metformin 750mg two times per day) GERD (despite being on Nexium) High Triglycerides (despite treated with Niacin 500mg daily) Can anyone help?

I have been approved! I sent in all of my paperwork on June 11th and they closed my case because I did not have a physical or bloodwork within the last 60 days. The third party (Alicare) also insisted that they had their own requirements seperate of what is in my benefits summary. I argued this point, andI went for my physical yesterday and bloodwork the day before. I submitted the updated information this morning with a somewhat personal letter. Less than a few hours passed and the Union had called to say that they had waived their right for third party approval and have approved my surgery! In case anyone is wondering, my insurance is Cofinity.

OMG!!!! I am SO FRIGGEN EXCITED! I just got a call..... I HAVE BEEN APPROVED! My husbands Union re-opened my case and called my surgeons office with the approval and pre-auth code. I call Monday morning to get my surgery date. THANK YOU notime and Amy for helping me get this letter out. I did some tweaking and made it quite a bit more personal and apparently it worked. You guys rock!. I feel like I won the lottery!! YAHOOOOOOOOOOO!

Thank you to both Amy and notime! I will get this into a letter, add a little personal info and send it off. I will let you know as soon as I hear something!

Amy, I will post here in case I confused others as well. My insurance company did not agree to cover my surgery yet, they just agreed to follow the guidelines outlined in my summary plan description instead of the extras the third party was asking for. Does that make more sense? I know it is confusing, I am confused myself!

You look FANTASTIC! Congrats!

I should have mentioned that my pre-cert was not denied, and she stated they will not deny it unless I state I am not willing to comply. Frankly, I DID comply and I am not willing to play games with them. I am also not willing to beg for them to approve a procedure they state they cover. Has anyone had a similar experience? Where you were asked to go far above and beyond the listed requirements?

So I called today to check on my case and ended up in tears by the time the phone call was finished. Let me start by saying that my carrier is Cofinity through my husbands Union. They have 'claims management' through a 3rd party, Alicare whose name I easily remember because everytime I say it i think 'all i care' about is MONEY. I have been working for since 2009 to either lose this weight on my own and not need surgery or get approval for surgery. In 2009 and 2010 I was on a medically supervised diet. Once a month I went into be be weighed. They documented my Weight Watchers, exercise, curves visits, Nut visits, Phentermine use etc. My medications are clearly listed throughout my records (phentermine for WL, metoprolol 100mg 2 x a day for high blood pressure, 1000 mg metformin for type 2 diabetes (borderline) and PCOS...the works. Please take a min to read my requirements for WLS writen exactly as they are in my benefits booklet. 11. Bariatric Surgery Bariatric Surgery will be certified and covered by the Fund (subject to all deductibles and co-pays) where the person seeking coverage for Bariatric Surgery submits documentation that all of the following requirements have been met: 1) the patient has a Body Mass Index of 35 or greater with co-morbidities, or a Body Mass Index of 40 or greater without co-morbidities, 2) the patient has either a) completed an approved weight loss management program followed by a 12-month maintenance period, attempted but did not complete a weight loss management program because the patient was medically unable or because surgical intervention was recommended, or c) did not attempt a weight loss management program because the primary care physician did not support that as a treatment option based on presenting co-morbidities, and 3) the patient has undergone psychological assessment establishing his readiness and ability to comply with post-surgical dietary requirements. All requests for bariatric surgery are reviewed by the Fund’s case manager for medical necessity and appropriateness. As of May i have met and exceeded all of these, I was feeling very confident in my approval. Well....now the 'case manager' said that their requirements are different than they are listed by my husbands union. They said that my documented weight loss attempts were too long ago (ending Dec 28th, 2010 / 18 months ago) It should be noted that as stated above the union office required 12 months before covering ANY pre-testing directly related to the surgery, therefore this was all started after the 12 months which is why we are now 18 months out) She then started spewing off ridiculous requirements such as weekly nutritional appointments (which they do NOT cover), at least 6 visits for psychology, H Pylori testing, exact date of diagnosis for HBP and metabolic issues, monthly BP recordings for the past 24 months..the list goes on and on... Can they do this? I seriously want to scream.

Arrrggggggggggg. See my post in the pre surgery section :/

On the 7th working day...still waiting.

Hi guys. I am at the point where I want to set my goal weight. I am not sure what is realistic? My current weight after losing a few pounds from dieting is 211 (my surgeon told me not to go any lower before surgery) I am 5'4", medium bone structure, medium muscle tone. What is a realistic weight to get to?

So, up until about 10 minutes ago, I have been incredibly happy about the possibility of getting surgery. Let me start by saying I have a great life. I have a husband that loves me, regardless if I am the 210 pounds I am today, or the 130 pounds I want to be. I have everything I need, and some of what I just want. After a great weekend with lots of friends and family I sat down and got to thinking..... In all honesty I think that my weight is the only thing that I do not like about my life/myself. All of my life I have been at least slightly overweight. It has been the first thing I think about every single morning since I have been 8 years old. The extra pounds have brought on PCOS, hypertension and I am pre diabetic. While yes, these things all suck, what if something goes terribly wrong? Also, this might sound weird, but I am worried that I won't be the same person with the lost weight. I worry that my weight is part of who I am. Does this make any sense to anyone? I feel like maybe I am 'the funny one' because I always had to be to stand out, or the 'nice one' because who likes a bitchy fat girl? To those that have already been sleeved, I am curious to know if it has changed you? I hope it does not me, because I would totally be my best friend.

You are doing GREAT, Kathy! Keep pushin!

If you fuel your journey on the opinions of others, you are going to run out of gas. Do what works for YOU. Agree to disagree. Let's get back to supporting one another now.

I have slowly started my pre surgery diet and people have already begun asking. I have told them that I am having corrective surgery in July, and I am preparing my body for a liquid diet. If someone asks what they are correcting - I reply with 'upper GI' and leave it at that. Only one (nosey!) kept pushing and after a minute or two told her that my medical issues were frankly none of her business. I do not feel like I am being untruthful. i AM having this surgery to 'correct' my weight and I am having surgery in this area. My medical business is between my doctor and myself. It is no more anyone's business what kind of surgery I am having than it is what color my panties are.

My paperwork was also sent today. Best of luck to you!

Best of luck to all of you.

Thanks so much guys! I already feel a bit better!

Hi Izzy, I have not been sleeved yet, but if you do not mind, I will follow your progress. My starting weight is within a few pounds of yours, and I also have PCOS and Type 2. I will be sleeved in July.

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Wondering - Sorry if my post upset you that was not at all my intention. That just seems like a massive amount of calories for a sleever. My doctor advised me that calorie intake would have to be 1000 calories or less to maintain weight loss. Admittedly, I am not very knowledgeable on this topic. I have PCOS, and can go ten pounds up or down every week, so I guess I did not see the weight gain as significant as others might, I hope you figure out what is going on and begin losing again.

How in the world do you fit 2300 calories in a sleeved tummy? I only ask because I eat around 1400-1600 a day without currently, and that is what got me to where I need to be sleeved!