Denial Insurance Mary Go Round Making Me Sick...

[Heyher 581]

Sent in 1st request in September. That was denied. Peer to peer two weeks later and denied. 1st appeal denied 10/23. Sent what I thought was external appeal 11/7. Turned out to be 2nd appeal. That was denied 11/21. Sent in request for external appeal today. Called to find out what time limit ERISA self funded plans have for IRO decision. First I was told they only did one appeal and that's what was denied 11/21. And what I sent in today was 2nd appeal. And that most of the time UHC didn't typically allow external appeals on my plan. Then they tried to tell me WLS isn't covered under my plan. I was livid... It is covered. It lists it on the summary plan description. I have denial letters for first level and second level appeal. On the second denial letter it states to send for external appeal... Almost threw in the towel today. My mom said that's what they want. For people to give up and not fight. And that I had to fight for this because I need it like she needed the RNY. Just so sick of the games.

[HoosierGirl 780]

Heyher - hate to hear all that! My story is much the same. Are you going to keep working with the insurance or self-pay? I'm heading to Mexico in Feburary. I almost feel my insurance denial was a blessing as I became a much more educated patient in the process of waiting. Hope you have a good outcome...defintately understand your frustration.

[Heyher 581]

I can't afford self pay here in the states or in Mexico. So insurance or nothing.... :-(

[HoosierGirl 780]

Lindstrom Obesity Advocacy was helpful/knowledgable. It might be worth calling them to see what they think? http://wlsappeals.com/

[Heyher 581]

I know it's medically necessary.

I have hypertension, sleep apnea, acid reflux, arthritis, pre-diabetic, fibromyalgea, ms, and other things. It is my plan that has been my nightmare. They want me to be at 40+ for 5+ consecutive years. I can't do that with the ms. My grandma passed away at 62 because she was morbidly obese with diabetes. She had congestive heart failure because of her weight and health issues. We sent all kinds of documentation and my personal letter siting medical facts, family history, and reasoning for why I want the sleeve. I hope it works and the IRO can get past 40+ for 5+ years..,.

[Cathys12006 1]

What doctor are you using in mexico looks like I will be following you're..

[Heyher 581]

Looks like they have until Jan 19th to make a decision. Almost 7 months to the day that I decided to have surgery. I hope who ever does the external appeal really considers all the factors in why I need the surgery. Pretty sure I'll be calling once a week to find out the status.

Until then I'll be a bundle of nerves.

Also found out the only reason I was denied is because they are not allowed to deviate from the plan at all and my plan doesn't allow for any exceptions. Strict plan...