Do you have Group Health?

[DylanRae 71]

Hello,

Ok, I have a problem. I am fighting tooth and nail with my insurance, like most people I see on here do. I have Group Health insurance.. so I am lucky in the sense that I don't have to worry about my insurance miscommunicating with my doctors.. They all are the same people.. At the same time I am unlucky because this means I am restricted to all of Group Health's rules and whatever else.

Ok here is my story see if you can offer any assistance.

In mid December, I asked my doctor to send in a referral to the bariatric clinic for me to have Weight Loss Surgery. For the following 2 and a half weeks I called in seeing what the process was, and where they where on approving me. I had little doubt that I would not be approved, but was anxious anyway.

According to my insurance, you have to have a BMI higher then 40. I do I have 42, and slowly growing. You have to have tried at least 2 different weight loss programs in the past. I have, Vision Quest 'Biggest loser', and Jenny Craig. Not to mention, I have been on the Beyond Diet, all with very little success. And last, *this is where I get a little lost* I have to have one or more of the following diagnosis.. (off the top of my head) Diabetes, High blood pressure, sleep apnea, Hypertension, arthritis.. and a few others.

The reason I am confused: some nurses have told me that I do not need this qualification if my BMI is higher then 40 which it is. I only need it if I am below 39... and other nurses saying that, I absolutely have to have all the requirements listed above.

I do not have any of the diagnosis they list. But more then half of them are things that are on my doctor's radar. For example, all the woman on my mom's side of the family have diabetes. It is a mixture of type one and two.. (part of that might be misdiagnosis simply because my great grandmother did not have the same doctor resources that I do) I am now diagnosed with what they call PRE-diabetes.. which apparently does not count enough.

Second, I have (in the last year) been under careful watch for sleep apnea. That also runs in my family, and my symptoms are only getting worse.

There are several others. All of them, I am close but not close enough, according to the list of diagnosis I have to have to qualify.

So, back to the waiting.. I finally get a letter saying that I am denied. And spend hours on the phone trying to find out who I can talk to to get this changed. Or at least will tell me what I need to do in order to get this request approved. After several round about conversations, I finally send in a second request, with my appeal.

In my appeal I explain in detail how, my life will benefit from this surgery, and after care. I talk about how the whole reason why I am pushing for it so hard is because I do not want to get the listed diagnosis... when there is proven medical record in the last year alone, that my symptoms are getting worse, and possible causing other issues.

It is now the end of week one, after sending in that letter, and I am feeling less hopeful this time. What sort of things can I use in my advantage to get this approval happening?!?! Please any advice is helpful.

Dylan

[Sleeveless in seattle 208]

I have group health Alliant plus so it is the most flexible of all their plans and I can see any doctor I want. On the flip side, bariatric surgery is an exclusion on my plan so I just paid almost 20,000 for my upcoming surgery. Is it included in your plan? If it is included and you were denied then they should be able to be specific about what you need to do in order for them to approve and pay. The phone operators for group health don't generally know what they're talking about the times I've needed to call. I would check your benefit book and see what it says. Also, if the doctor had to put in for it then maybe he can tell you what hoops you need to jump though.

[DylanRae 71]

Thanks! Yeah I know that it is covered under my plan, but I will still have to pay co-pays and that sort of thing. It comes out to be about 500$. I got a letter the other day saying that the appeal team or who ever they are have requested an extra 30 calendar days on top of their basic 2 weeks. They said in the letter that if they need more time then they can have a total of 15 days with written consent from me.

I'm freaking out a little, is the fact that they need more time to look it over a good thing? Because they are not just shooting me down as quickly. Or am I going to end up just as disappointed at the en of this anyway. I feel like if I could get someone on the phone who had any weight on the decision then I would have a running chance. I don't sound very good on paper.

Anyway, I'm glad I'm not the only GH person. Thanks.