m&nsmama

I am at a loss. I am trying to keep this as brief as possible, so forgive me if you get lost in the muck and the mire. 1. Decide in August to have lap band done w/ Dr. Liu. 2. UHC rep says won't be authroized b/c Dr. Liu doesn't accept insurance. 3. Confirmed by rep 2. 4. Rep 4 says no way. Will be covered at 90% of what's eligible. Must turn in predetermination request. 5. Ask reps 4 & 5 and coordinate w/ Dr. Liu staff what is required (just paperwork from his office. Submitted. 6. Denied. Not a covered benefit. 7. What? That's not what reps 4 & 5 said! 8. Oops. You're right. Denied because no proof of morbid obesity for last 5 years. 9. Submit proof. 10. Denied for not submitting proof of morbid obesity. Argue with Reps 6 & 7 for 45 minutes on the definition of "proof." They say HEIGHT AND WEIGHT IS NOT PROOF. :smile2: Must be a ICD-9 diagnosis from a chart. I said YOU CAN'T GET AN ICD-9 DIAGNOSIS OF MORBID OBESITY W/O THE HEIGHT AND WEIGHT! 11. Get transfered to medical review unit. She tells me I was denied because I failed to submit proof I participated in medically supervised weight loss programs and do not have high blood pressure, heart disease, Diabetes, or obstructive sleep apnea. WHEN WAS ANYONE GOING TO TELL ME THE REQUIREMENTS OF MY OWN PLAN? I've participated in countless weight loss programs (medically supervised ones, too), but the closest thing I have to any of the above is insulin resistance. I feel like I am getting the run around, and no matter how many hoops I jump through, they will find a reason to deny it. Anyone get lapband approved with a situation similar to mine?

I am a patient of Dr. Liu in LA. UHC has denied me for reason and reason after reason. The latest is for not completing a 6 month weight loss program (medically supervised). I'm willing to do the medically supervised program--what can it hurt? So, are there any Dr. Liu/O Band Center patients who completed a 6 month program? If so, where did you go? Thanks so much. :huh2:

UHC isn't going to budge on the 5 years of BMI >40, despite only missing it by one weigh in in 2003 that put me at around 38. Sigh. So, my next step is to submit under BMI >35, but with comorbidities. I have insulin resistence, but not diabetes, so that one's out. The only one left that I might have is sleep apnea. My question is this: was anyone out there shocked to discover they had sleep apnea? My husband thinks I have it because I am always tired and wake up constantly at night to use the bathroom (true). I also snore all night long, according to him. :w00t: However, he never hears me gasp for breath or anything like that. I'm going to get the sleep study done regardless, but isn't this something that he would notice me doing, if not me? Thanks for the replies! :eek:

I know, you don't really know if congratulations are in order! I am happy that I may have the surgery, but having sleep apnea as severe as I do is definitely worrisome. Hopefully it will improve after I lose weight, because that mask is the pits.

Well, I had my sleep study. :thumbup: The results are in. I "kind of sort of" have sleep apnea. (That's an understatment) On my back, I averaged 104 events PER HOUR. On my side, I averaged 34 events PER HOUR. So, on average, I have 49 events per hour, which means I actually have SEVERE sleep apnea. The doctor wanted to know how much caffeine I drink a day, and I told him the truth: NONE. He couldn't believe it. He said with the number of events I'm having, he doesn't understand how I am functioning. My brain is "awake" almost every minute of the night. I need to be on a c-pap immediately, for sure, but he doesn't think getting cleared for surgery will be a problem based on my study. I'm just posting my results for the people who told me not to lose hope, and for those out there like me who think they don't have sleep apnea. Believe me, you don't have to gasp to have it! THANKS!!

The only comorbidities my UHC plan considers are 1. Diabetes 2. High blood pressure 3. Severe Obsstructive sleep apnea 4. Heart disease I have PCOS and insulin resistance, but those aren't considered under my plan. If I have sleep apnea, I get the surgery. If I don't, I'm out of luck.

Wow! Thanks for sharing your story. The more and more I hear, the more I am convinced I may actually have sleep apnea.

:biggrin: lol Acadiamom! You're email the other day to me actually gave me hope! I was praying your situation wasn't just an anomaly and other people experienced the same surprise diagnosis. Yes, let's talk about our corporate friends. I'm glad UHC seems to be understanding the intent a little better. Funny how that works. But, seriously, if Friday's phone conference was any indication (not to mention the other things coming down the pipe), we need to get our surgeries ASAP!

Um, wow. I am always tired in the afternoon and wake up with headaches all the time. I can't believe this is a strong possibility because I don't wake up gasping, but maybe it is.

Ugh! My UHC plan is a corporate plan, too. My husband works for a pharmaceutical company. MY BMI is over 40, but on top of telling me that doctors notes of height and weight are not enough (see new post in this section) they are telling me that I have to have the co-morbitities WITH a BMI of 40! :tt2: I had them read to me the plan requirements (because God forbid I be allowed to see a copy of my own plan!) and it states clearly BMI 35+ morbitities. I am beside myself. My corporate advocate told me last week she can no longer help me once it's gone to appeal. But I'm not buying it. Thanks for the tips on obesitylaw.com and Allergan. I'll look into it. I wish you luck! p.s. My husband's company is on the east coast, so I wasn't able to call them in time today for a copy of my plan. Hopefully I can reach someone on Monday.

My insurance co (UHC) states that in order to prove morbid obesity I MUST have a diagnosis in the actual medical records for the last 5 years. Proof via height and weight (in a medical chart, of course) is not sufficient. It must be mentioned in the notes and I must be treated for it. i.e., at my OBGYN appointment each note should state that I am morbidly obese and it caused me some sort of problem. To me, this is splitting hairs to the nth degree and just an easy reason to deny procedures. Does anyone else's insurance require this detailed level of documentation?

Ruth, I have a ton of sites, blogs, books, etc. Probably your best bet is to start with Alissa Cohen (alissacohen.com) or her raw food forum, rawfoodtalk.com these are great places to get a lay of the land. She has an incredible raw "cook" book with plenty of recipes. I highly recommend it. For inspiration, Google Angela Stokes. She lost over 160 pounds eating raw foods, and is now very well respected in the community. She has her own website and blog. I am waiting for approval for the band, but you can bet during recovery I will be feasting on green smoothies and the like. When I get to the soft food stage, I have in mind many raw food recipes that include soaked, blended nuts and fresh vegetables. I think it will be a great way to get the needed Vitamins and Protein I'll need in a soft, small quantity. This is the green smoothie my son and I drank all the time last year. He was 3 at the time. Young Coconut (or 1 cup water) Frozen banana Frozen pineapple spinach Agave or other natural sweetener as needed. Blend until smooth. The most popular book out there in terms of the benefits of green smoothies is Green for Life by Victoria Boutenko. The Boutenko's are a very popular raw food family. There are a host of other raw gurus I can mention. Most will tell you 100% raw is best. I disagree. The consensus, both scientific and popular, supports a diet of roughly 75% raw foods. For me, a 100% raw diet was expensive and unrealistic. I do hope to get to 75% eventually, though.

I did raw foods for a while last year, and it was the best I ever felt in my entire life.

While studying for the bar 4-5 years ago, I became addicted to McDonalds, and fast food in general. Now I can't seem to go for more than a week w/o fast food. Really I have it about 2-3 times a week. The same goes for ice-cream. Since your lap band, how have your addictions to food changed? Do you visit a support group regularly? My doctor doesn't seem to offer much in the way of nutritional counseling, therapy, etc. and I am worried I will defeat the bad with junk food--maybe not initially, but down the road when the newness passes.

Long story short: I had planned to go with Dr. Liu. Pros: He comes highly recommended, has done 1200+ procedures and has great outcomes. Cons: Office staff, no support groups, psych evals, or nutri-counseling. Office in LA, and I'm in Riverside. Today I received word from my insurance that I was denied. I won't know why until I receive the letter, but I suspect it's because he is not contracted with UHC--or with any insurance for that matter. The insurance reps I spoke with last week suggested it would be a problem. I decided to look at physicians in my area. I found one. Dr. Coon. Pros: His reviews are great. Everyone seems to love him as a person, not just a physician. He is very concerned with after care. He has monthly support groups, psych evals, nutritional counseling, etc. He is 10 minutes from my house. He is/works in a COE. Cons: He's only done 100+ bands. The last four years he has spent doing bypasses. His wife (who works at the office) says it's because he wanted more studies to come out before he jumped on board. With everything I have read about him, that seems likely. Many of his patient reviews talk about the concern for patients, outcomes, etc. So, fancy LA doc with high numbers? I would have to start the appeal process with my insurance. Or, local doc w/ a great personal reputation but not much in terms of procedures? For some reason my gut (no pun intended) has always said Coon. But, being from a medical family, that little red flag starts to wave every now and then when I think of how few procedures he has done.

I don't really know where Dr. Liu is from. I saw him in his own private office, but now I hear people talking about Beverly Hills Physicians and a few other groups as well. I suspect he does some subcontracting or does independent work through other groups. Thanks for your opinion on the matter. :tt1:

Hi, I'm wondering if everyone is still happy with Dr. Coon? I was denied by my insurance for surgery with Dr. Liu. Any input would be greatly appreciated. :tt1:

Yeah, I just did some research and he doesn't seem to be the one speaking regularly--he has monthly guest speakers that I hear are very good. And, I read on his site that the group is open to the public. That's good. Thanks for all the comments so far! :tt1:

I think I should participate in some sort of support group. The only problem I have is where. My surgeon, while very well regarded and experienced (1500 procedures), doesn't offer one--that I know of. He is also in the LA area, and I am about 1.15 hours away in Riverside. There is one doctor here in town, Dr. Coon, who is very strong believer in support groups and has a good one tailored to how long the person has been banded-but he has done at most 100 procedures. I can't imagine asking to crash is support groups. I think that would be pretty damn rude. Are there any support groups out there that are not tied to a physician's practice?

Best of Times: I had my endoscopy today and my NINE ulcers from last year are healed. Worst of Times: My insurance is now telling me that they will not pay for my procedure because my doctor (Dr. Carson Liu) is not a contracted provider. I have UHC, 90/10. I have excellent insurance. We have never had a problem with contracted/noncontracted before. My husband is on the line with Human Resources at his company in hopes this is all just a misunderstanding. Back to the drawing board, I guess. :omg_smile:

Well, that's just weird. The woman handling billing, Claudia, told me that they collect $2000 up front for every surgery--regardless of what is covered. If there is a credit, they return it to you after the insurance has paid. You can't schedule your surgery w/o paying, and if you cancel 10 or less days from the date of surgery, you don't get the money back at all.

That's great! According to the person I spoke with today on the phone, that won't be the case for me. I don't think it sounds right, which is why I called HR and will call the insurance tomorrow (again) but this time speak with a supervisor. So then Dr. Liu refunded your $2000?

Grateful Heart--can I ask who you are seeing for your lap band?

Thanks, Grateful Heart. I have a call in to my husband's HR department and I'm going to call UHC again tomorrow because I always thought that when you see someone who is not contracted your coverage drops to 70%, so I'm confused. I was ready to pay $1700-$2000 out of pocket, but for my insurance to not cover any of it? Something just doesn't seem right. Dr. Liu's office says he is not on ANY insurance plans. He does not accept insurance--period. (He'll bill for you, of course) This allows him to balance charge the patient the remaining balance, rather than accept the reasonable fee dictated from the insurance.