Insurance denying - Need records I can't come up with

[jas84047 72]

I've been working on my prerequisites for my Sleeve for almost a year and have been fighting to get it authorized for the past 3 months. I thought I fulfilled all my requirements but after 2 1/2 weeks of waiting for my insurance company to approve/deny they called me this morning. They cannot approve without medical records from my PCP for a 6 month period showing at least 3 visits with weights where I haven't gained - not even a single pound! But... the 6 month Dr supervised diet period does not count! I don't go to my PCP that often. I try not to. I thought that's what they wanted you to do! I've already submitted records from 2012-2013 like requested. I'm livid and freaking out. I've waited and done everything and if I cannot get this covered in the next few months I will not be able to have it until 2016 due to my work schedule. And, by then I will have to start all my prerequisites over because they will be too old. What now? What can I do?

I'm sick about this. And what makes matters worse is I work for the company my insurance is through! I understand all the ins/outs of insurance better than most!

Thoughts anyone? I'm seriously stuck. :'(

[marybowlus 17]

I didn't see where you mentioned the name of your insurance company.

[TEXASLADY52 264]

Call them....if you have already done so....take a chance of getting a different person that will be more understanding. I got hold of one that sid "I'm not suppose to tell you this".....be as nice as you can be....pour your heart out to them try to get them to understand what you are going through and how bad your need this surgery. Don't give up......keep calling until you get someone that will help you.

[jas84047 72]

@@marybowlus, My insurance company is SelectHealth (IHC/Intermountain Healthcare). It's the largest company in Utah. I work for the hospital side of the healthcare company, but I work closely with the insurance side so I know the process.

@@TEXASLADY52, There are what's called Case Managers for large procedures or diseases and so it's only one person. I can't really talk to someone else because they will just refer me to my case manager. There's also another 'hiccup' where my SIL is a Case Manager for the company and since none of my family knows I'm doing the surgery I don't want to cause too much of a ruffle in that department.

I think the biggest issue I have is the fact that after everything I now have to go to the doc 3x in a 6mo time period just so I can prove my weight?! That seems like a strange and very costly thing to do??

[Chele H 427]

Have you done all.of the prep without seeing a surgeon? I met with my surgeon before any of the pre-prerequisites. He had an insurance coordinator and her sole job was making sure all insurance requirements were met and dealing with the insurance company for the patient. Can you make an appointment for a consult and bring all of your documentation?

[jas84047 72]

I saw the surgeon last July for my first visit and afterwards met with the office lady who gave me all the prepreq's the insurance would require. I did those in the last 10 months and sent them all into my surgeon's office insurance lady in Feb. The insurance coordinator at my surgeon's office was the one who submitted everything I've done that was required on 4/27. I've followed it all by the book. This is just a new requirement I wasn't aware (and I guess neither was the surgeon's insurance lady, who I may add is not very bright) of a year ago that will add another 6months too I'm afraid.

[Chele H 427]

I saw the surgeon last July for my first visit and afterwards met with the office lady who gave me all the prepreq's the insurance would require. I did those in the last 10 months and sent them all into my surgeon's office insurance lady in Feb. The insurance coordinator at my surgeon's office was the one who submitted everything I've done that was required on 4/27. I've followed it all by the book. This is just a new requirement I wasn't aware (and I guess neither was the surgeon's insurance lady, who I may add is not very bright) of a year ago that will add another 6months too I'm afraid.

Well that is unfortunate that you do not have a good insurance coordinator fighting for you. Since this is a new requirement could you possibly file an appeal showing started the process prior to the new requirement? Best of luck You, don't give up.

Edited May 5, 2015 by Chele H

[jas84047 72]

Thanks Chele! I won't give up... but probably will be bitching about it for a bit. LOL

[jas84047 72]

Just wanted to update y'all....

I sent in my emails from my pcp to the insurance showing I had 'supervision ' during the 6mo nutritionist program and after threatening legal action got my surgery APPROVED Thursday! Now I wait to get onto my surgeons schedule. Looking like my VSG will be sometime in June! Soooo excited!

[dandylion_23 5]

Who is your surgeon? I'm curious! I'm going to Dr. Cottam in SLC.

[jas84047 72]

Who is your surgeon? I'm curious! I'm going to Dr. Cottam in SLC.

Dr Cottam

What part of the process are you at? Their office staff is a JOKE! :/

[dandylion_23 5]

Found it! I am still waiting for my first appt because I'm in Nevada and he comes here once a month. I don't have to deal with his staff there much but what staff I have dealt with are very rude. I mostly talk to his nurse here who is absolutely amazing and has had the sleeve too.

[jas84047 72]

@@dandylion_23 Yes the staff is very rude! They also are extremely slow and do not return calls or emails. When they do return emails they are snippy and short. I've had this problem with both the insurance "specialist" and scheduler. In fact, the scheduler called today to finally give my date after saying she'd call me back last Thursday. At the end of the call she said she'd send me an email with all my preop details and appt. No email yet....

Here's hoping you have a better experience.

I seriously considered going elsewhere but I'm already this far in.

[dandylion_23 5]

How long has this process been for you so far?

[jas84047 72]

I made my initial appt sometime in may 2014. The earliest initial consult appt was July 2 2014. I started what I was told was my 6 mo diet program in Aug 2014 & was done with all pre-reqs in Feb 2015. When the insurance specialist finally got around to submitting to my insurance in April 2015 I found out I didn't need the 6mo diet program I was told to do because I only needed 6mo worth of PCP notes stating we discussed my weight & diet. Because I see my doc regularly I could've had my surgery last year. So... long story... this process has taken A Year!