May Not Be Approved! WHAT?

[sunnyd 32]

SO I finally finish all my requirements after many months of appointments and as the doctor's office is getting ready to submit my paperwork to insurance- they say I may not be approved because I don't have 3 consecutive years proving my weight/BMI. Ok so I have a high BMI documented in 2008, 2010, and 2011. For some odd reason I never went to the doctor in 2009 and therefore do not have my weight recorded for that year- and because of this I may not be approved. I would have to wait a whole year to try again if it is denied for that reason. I had wanted to wait until June/July to have the surgery but due to my endoscopy showing ulcers and hernia the surgeon wanted it rushed and told me I shouldn't wait that long- but now I may have to wait a year. What? AAUUGGHH! I'm going crazy!!!

Do they really think I had a high weight/BMI in 2008 but lost a ton of weight in 2009 and not have a high BMI and then have a high weight/BMI again in 2010. Come on- really?

Anybody have a similar situation or any advice???

[MINI-Me 196]

Just take a deep breath ... I'm sure things will be fine. If you are denied, you can appeal. There have been some very successful appeal letters shared out here & I'm sure others can help with that.

For now ... think positive thoughts and prayers. We'll do the same for you.

WLS is stressful enough without the added pressure you got today. Sorry.

[Disney 20]

SO I finally finish all my requirements after many months of appointments and as the doctor's office is getting ready to submit my paperwork to insurance- they say I may not be approved because I don't have 3 consecutive years proving my weight/BMI. Ok so I have a high BMI documented in 2008, 2010, and 2011. For some odd reason I never went to the doctor in 2009 and therefore do not have my weight recorded for that year- and because of this I may not be approved. I would have to wait a whole year to try again if it is denied for that reason. I had wanted to wait until June/July to have the surgery but due to my endoscopy showing ulcers and hernia the surgeon wanted it rushed and told me I shouldn't wait that long- but now I may have to wait a year. What? AAUUGGHH! I'm going crazy!!!

Do they really think I had a high weight/BMI in 2008 but lost a ton of weight in 2009 and not have a high BMI and then have a high weight/BMI again in 2010. Come on- really?

Anybody have a similar situation or any advice???

No, they don't think that, they just go through your application for surgery with a fine-toothed comb to find ANYTHING they can to deny you. It is just WRONG, but it's what they do.

[sleevehopeful 0]

I am going through the same thing!!I have been dealing with this since feb 2010! I cant get my insurance co to pay for it! I just got denied AGAIN! So I am never going to be able to have the sleeve done because I can't pay out of pocket! I am so disapointed! Hope it goes better for you!

[feedyoureye 3,087]

I am going through the same thing!!I have been dealing with this since feb 2010! I cant get my insurance co to pay for it! I just got denied AGAIN! So I am never going to be able to have the sleeve done because I can't pay out of pocket! I am so disapointed! Hope it goes better for you!

Never is a long time. Start saving a little each month. Even a little bit to keep the dream alive. Your insurance may change, you may get a new job with different insurance, you may save the money to go to Mexico or another surgeon in the future, Never say Never!

[thinoneday 445]

I was self pay cause my insurance didn't pay for this surgery I got a really good rate from my bank 3% so I borrowed the money. . .sure it's like buying a car but at least I'm not fat anymore! Good luck

[sleevehopeful 0]

Thanks for the encouraging words! Sometimes it is hard to stay positive! If I had good enough credit I would take a lone out tomorrow!! I think it is well worth the investment but when life has been hard you kinda have no options at this point...other than to try to save $!

[Blsmbry 13]

Hello,

First of all I hope everything works out well for you. This insurance process can put you on a roll-a-coaster ride that will try to throw you if you're not strong enough. Hold on and don't give up. I was denied intial and was denied again because my 5 year history was not included. A couple of days ago my insurance re-submitted with my 5 year history for pre- determination so hopefully I'll be approve this time. Also I wrote my own appeal letter and I will like to share it with you. You can edit or add what pertains to you. Good Luck. Keep us updated!

<P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal>I am writing this letter to appeal United Healthcare decision to deny coverage for laparoscopy, surgical, gastric restrictive procedure that was denied. Based on the letter of denial dated December 22, 2010, this procedure was denied because “ the minimum of five year weight history was not met. Therefore, this service is not a covered benefit under plan. <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal> <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal>I was referred for this surgery by my PCP, who is very concerned about my health because of severe morbid obesity. I am a 32 year old morbidly obese female who is 5’4 iches tall and weigh 298 lbs., giving me a body mass index of 49. The body mass index is calculated by dividing a person's weight in kilograms by their height in meters squared. When a man's BMI is over 27.8, or woman's exceeds 27.3, that person is considered obese. The degree of obesity associated with a particular BMI ranges from mild obesity at a BMI near 27, moderate obesity at a BMI between 27–30, severe obesity at 30–35, to very severe obesity for patients with a BMI of 40 or greater. Therefore, I may be classified as being very severely obese. The annual number of deaths in America attributable to obesity has been estimated to be 300,000 deaths per year With my abnormally high BMI, I am at an estimated 190 percent increased risk of death at my present weight. <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal> <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal>After you reviewed my additional clinical information I know you have found to fact, that I have co morbidities of Obstructive sleep Apnea, Polyarthralgias, and Gerd. I have made many, many attempts to lose weight and this has gone on all my life. My previous over the counter weight loss aids, such as Slim Fast, South Beach Diet, Atkins, Hoodia pills, Alli, Slim Quick, and LA Weight loss was only a 5-10% success. I would lose some weight then gain it all back, and more. As you can see, I have spent all my adult life trying to lose weight. I am now at the point where everything is an effort. I have functional impairment in the activities of daily living. This dysfunction impacts sleep, recreation, work and social interactions. I am having significant adverse symptoms from my obesity. I have difficulty standing. I have difficulty performing my daily activities, and in participating with my family in recreational activities. I suffer from sleep apnea and acid reflux. I have arthritis and pain of my weight-bearing joints. An increase in body weight adds trauma to weight bearing joints and excess body weight is a major predictor of osteoarthritis of the knees. This is a mechanical problem and not a metabolic one. Weight loss will markedly decrease the chance of developing osteoarthritis. <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal> <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoBodyText>Both my PCP and I believe that laparoscopy, surgical, gastric restrictive procedure is medically necessary and will significantly benefit my health. I believe that laparoscopy; surgical, gastric restrictive procedure will increase my overall health physical, mentally, emotionally, and even finically. <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal> <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal>However, I have included additional clinicals that will show a history of morbid obesity over a five-year history. I have also included some pictures that will show a life long history of obesity starting from childhood. My prayer is that you will take into consideration to accept these pictures as a documented five-year plus weight history and reverse your denial to an approval for laparoscopy; surgical, gastric restrictive procedure. <P style="MARGIN: 0in 0in 0pt" class=yiv318147326v2> <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal>Economic costs of Obesity:

Obesity has been shown to directly increase health care costs. In an article in the March 9, 1998 issue of the Archives of Internal Medicine 17, 118 members of the Kaiser Permanente Medical Care Program were studied to determine the association between body fatness and health care costs. The results showed that patients with BMIs greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMIs under 30. <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal> <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal>Indirect costs:

Americans spend an additional $33 billion dollars annually on weight-reduction products and services, including diet foods, products, and programs. Most of these expenditures, as is evidenced in this case, are not effective. Rather it can expected that they will continue to gain weight and the costs of co-morbid conditions, including the ones they already have and ones they surely will acquire as time goes on, will far outweigh the costs of gastric bypass surgery that we are asking you to please approve for me. <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal> <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal>As you can see I have exhausted all the traditional ways to lose weight. The gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic sleeve gastrectomy) is an approved and proven means to permanently lose weight. Please approve this surgery for me by reversing your denial to an approval. I would like to thank you in advance for your time and effort in making this happen for me. Thank you very much. <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal> <P style="MARGIN: 0in 0in 0pt" class=yiv318147326MsoNormal>