Went to the appeals board today...

[jillrn 0]

It looks really bad-- everyone was great except this lawyer they had there she had every reason under the sun why they shouldnt have to cover it. Some of them were just plain untrue--- she tried to say that the band and the high number of complications related to the band is more expense the the cost of obiesity! She has no clue- I am a nurse- I see people with heart attacks, stroke, cancer and diabetes everyday run up hundreds of thousands of dollars in one hospitalization. It really seems like their mind is totally made up before you even appeal. I should know their answer with in a week but I am sure it in NO WAY, So I have to figure out what the next step is. I am going to look into Indiana's Dept of Insurance and see what I need to do to file a formal complaint and get an independant appeal board to look at the case. I could just cry..... I dont know what to do to lose this weight-- I have tried everything

[nanahanna 1]

Jill, I am so sorry! Don't give up. I wrote one of the owners of the company my husband works for (he is an email buddy of mine) and asked him why they don't pay for WLS and he said that since they are self-insured they cannot afford to and that they try to provide insurance for things that employees don't have any control over. In other words, I should be able to control my weight on my own. He did send me Gov. Huckabee's book though and it was very inspirational. I am still not giving up though. I will wait until I get on Medicare in a few months and try them. LOL.

Sharon

[ReneBean 3]

Jill -

Of course their attorney had every reason why they shouldn't have to pay. That's her job.

Chances are good that they will say "no" if that was not an INDEPENDENT review board.

Find out what you have to do to get and INDEPENDENT review - I had to go to the State of CA - and you may have to go to the State of IN. It's all part of the process. In the mean time, YOUR job is to collect documenation to argue all the points that the insurance attorney erroneously made. Get some statistics on paper regarding the cost of a hospital stay for a heart attack, or the cost of long-term diabetes care vs the cost of the band surgery and related complication rates & expenses.

The numbers won't lie. If you are currently taking medication that could reasonably be expected to go away if you lose the weight - stack the monthly cost (to the insurance co) of the meds you are taking against the cost of say, 3 fills a year. State Review Boards love documentation.

Keep your chin up! Go get 'em.

I am keeping my fingers crossed for you.

[Mvpo8961 1]

JillRN look at Cigna's Healthcare Coverage Position Statement for Bariatric Surgery. There are a number of references that you could pull for your appeals. Go to www.cigna.com and do a search for 0051 this will pull up an alphabetical list. From there go down to bariatric surgery. They have a 20 page position statement on BS with 88 references. You should be able to pull some of there references to support your case. M:Bunny

PS anybody with BCBS insurance should look at the references that Cigna uses from BCBS Technical Evaluation Center. It might help with appeals also. M

[jillrn 0]

Many of you have followed my saga trying to get this surg approved and my appeals-- THank you for your support! I was denied by Anthem for my second appeal. I am insured through my dh and they have always covered the surg until Nov 1 the same day my paperwork was submitted they excluded anyway ON TO THE GOOD NEWS!!!! I found out my work is covering it for 1000-1500 dollars!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! I dont have the insurance at my work though, I am PT but they said if I go FT I can pick up the insurance then I would be covered. I have been thinking of going FT b/c we need the money right now, but I would probably want to drop down to PT again next year or maybe even next fall. Is this ethically wrong?? I can still keep the coverage PT I have to pay more (which I will keep it b/c I will need it for fills right??) I am so excited I feel hope again for the first time in a while! I need this pray it works out ANyone have WAUSAU?????? thanks again you guys have been so supportive!!!! JIlll

JACK-- YOUR ARE SO COOL_THANK YOU!_ I AM GOING TO KICK SOME BUTT--I AM GOING TO KICK SOME FAT BUTT AND LOSE MINE!!!!

[Mrs Sabre 1]

Congratulations Jill; that is fantastic news!

[Mvpo8961 1]

JillRn I have been an RN for 23 years. Although presently I am a SAHM while homeschooling my 15 y/o. No it is not ethically wrong to flip to FT then when you need to go to back to PT. They are paying YOU for your talents and work not the other way around. Insurance is part of the TOTAL compensation package. My husband is an ICU manager and this is how they look at ins as part of the total compensation. You are a valuable asset to THEM. Go for it and be HAPPY. M