Insurance rejection letter

[lauri 0]

:think I got a rejection letter from the insurance today! Can I just say- They stink!!! I actually have some much stronger adjectives to describe them but I will spare all of you the cursing.

Our reviev determined that the denied services(Lap band) requested are NOT MEDICALLY NECESSARY based on the following:

There is no documentation of 12 continuous months of medically supervised weight loss program that includes nutritional therapy, behavior modification, supervised increase in activity, pharmacologic therapy-unless contraindicated-and maintenance support. This 12 month program must have been in the last 24 months. Programs such as weight watchers or Jenny Craig are not considered medically supervised weight-loss programs.

Anyways-I am upset to say the least. I have been through so much to try to get approved. How can they say it's not Med. necessary? With all of my medical problems, I am in the dr.s office atleast 2-3 times a month! Medical equipment for sleep apnea(which is probably due to weight!) Medications for depression, anxiety, migrains, etc...... Don't they understand that if I lose weight-many of these problems will go away?! I have so many thoughts and frustrations going through my head right now! This surgery has been the only source of hope that I have had that I might be able to actually live a normal life. I am trying not to have a "melt down" but I just feel like my rug between hope and hopelessness has just been yanked out from under me! What do I do now?

[hagerteresa 3]

Bummer Lauri, Don't give up yet though. Does your insurance policy say they cover WLS if it is medically neccessary or is it an exclusion? I have a friend who had the by-pass and her insurance considered WLS an exclusion. All she had to do was hire an attorney that specializes in weight related cases, he wrote the insurance a letter and the next thing she knew they accepted her claim for surgery. I am hoping the same thing will work to get my mom banded because our insurance excludes weight loss surgery as well and she doesn't have the money to self pay. You might have to do 12 continous months of doctor supervised weight loss attempts. Is your primary doctor supportive of the band at all? I doubt you would have to pay to go to a dietician but maybe your primary can help supervise you... I don't know... I had to self pay for my surgery in Mexico. I am sick of insurance companies as well and can add a few more "bleeps" to yours. Teresa

[leatha_g 4]

Very sorry to hear this, Lauri. I know you were really looking forward to getting the band. Alot of times, these insurance companies deny you first try just hoping you will give up and they will save money. My brother's insurance told him the same 12 month story. I'm not sure of the objective here. To see if your determined to lose weight or are they hoping you'll lose weight on a Dr. Supervised diet and you'll no longer need surgery? I'm not sure, but it stinks. I agree.

There are appeal letters on this site and some of the other Yahoo Bandster sites that you might be able to model something for yourself to appeal with . It stands to reason, if you are taking medications for weight related co-morbidities, it would benefit your insurance to help you to get more healthy in the long run. Something to this effect with backed up facts relating to the band and people who've had success with it might help you get approved. Don't give up! Show them how determined you are. But first, do make an appointment with your PCP, find out if you have ANY documentation discussing your obesity in your current records and see if he will back date his documentation of your weight loss to any reference he has documented in the past. I don't know how much this might help, but it's a start in the right direction. Good luck!

[DeLarla 22]

Most people say they can't afford to self-pay, and I can certainly understand that because I didn't think I could afford to. But I hit rock bottom, and I found a way. I got a loan from the credit union with payments $100.00 per month. I gave up getting my nails done, bottled Water delivery, and fast food to fit the band into my budget. My grocery bill has sliced in half, and I don't order at restaurants any more cuz I just pick at friends or husbands. Or I split meals with co-workers. It's doable if you want it really bad. My food bill was insane. I'd buy anything and everything to keep up my food addiction. Now I stop in 7-11 and just grab some Decaf. No more drive thru, no more convenience stores, no more take out or pizza delivery. The band pays for itself in 2 years. But you should do like Teresa said and keep fighting. The pen is mightier than the sword.

[Chris S. - L.I. 0]

Sometimes if you get your PCP to write a letter on your behalf stating any weight loss attempts you have made while under his care it might help. I would try to see if your PCP would help in this way. Don't give up!!!!

[DeLarla 22]

Chris, that's a good idea. I've been on Weight Watchers before while seeing my regular doctor, so that would count as medically supervised.

[leatha_g 4]

Yup and any time your doctor writes you a script for Meridia or Xenical, that's medically supervised.

[lauri 0]

Thanks to all of you! If it wasn't for all of you I really don't know how I could have made it through the past few months. You know the first thing I thought after I read the letter is-Will I still be able to hang with my friends at LBT.com? Well? I'm not out of the club am I?

I just got off the phone with my insurance and they said to get the 12 months documented blah blah blah....I will work on that end of it. Then, I called Dr. Cribbons office(band surgeon) They said that they will probably get the letter from the insurance in a day or two and THEN she said, "Oh, by the way did I tell you that we don't accept BCBS any more? If you do eventually have the surgery-It will be out of network." Thanks for telling me!! I wonder WHEN they were going to let me know that!

My PCP is supportive. Actually, I found out about the surgery through someone at the office that had had the surgery and lost alot of weight. I will be talking to her soon. I am not giving up. I am going to keep exercising and if it is okay with yall- I will continue to spend time here. Maybe I will save money and go to Mexico. I am open to anything! Oh! It's time for me to get my butt down to Curves for work out #2 today! They close in an hour. Love you all! Thanks for being my friends!!!!

[lauri 0]

Yup and any time your doctor writes you a script for Meridia or Xenical, that's medically supervised.

What are these and can you take them with Thyroid med and anti-depressants and such? I really am going out the door now. I will talk when I get back.

[La_madam 20]

Lauri..there are other ways..I went to Mexico and was a self pay..Dr. Ortiz offers financing through Capital One.so do other Dr.s in TJ..if you want this and your insurance will not cover you ..Go to Mexico. Many of us here have and have NO regrets. I sold my most convertible mustang to have this surgery thats how bad I wanted it...and I know when I'm thin I will want that car back but I also wanted this surgery badly and I was not going to fight with my insurance company and take months to do so..I'd probably still be fighting them 7 months later and now I'm over half way to my goal weight 67.50 lbs lighter

[claraluz 2]

I'm so sorry this happened. I know it must be very disappointing. My insurance company gave me the same story, but it was five years instead of one. I was probably my insurance company's dream because I just gave up and went the self-pay route. I wish I had appealed. I am no expert on insurance issues, but just from reading the boards I have learned that your policy probably allows you only a limited number of appeals. So make sure the first one is as effective as possible. I would also consult the lawyers at Obesitylaw.com. They specialize in this sort of thing. And make sure that every time you visit your PCP, he puts obesity down as a secondary diagnosis. It's very frustrating, I know, but you can fight this thing! Or you can go the self-pay route. I thought about it like this: It wouldn't seem extravagant for me to pay $14,000 for a car. My life is more valuable than a car. And it is cheaper than that in Mexico.

Nancy

[Iluvharleys 15]

Laurie - I'm sorry to hear that. I know how you have looked forward to having the lapband. You have had lots of suggestions here, I hope you follow through with some of them. Lots of Dr. are offering payment plans now, so maybe you can work something out that way.

[lauri 0]

I am going to do what I can. Right now, I am just trying to regroup. If anyone knows of specific dr.s that will do payment plans, please PM me and let me know. In the mean time I am going to start making my dr. document everytime I fart! Oh wait-that's another thread! At any rate, she will be busy because I am going to Well, anyways I am not going to give up. My credit stinks and so loans and such are out but..our truck will be paid off soon so I could start saving that 500 a month and our house payment is supposed to go down in Jan. or Feb. - that's another 200. Lisa is right about fast food and such. I could save alot there. I will probably lose some weight that way as well. I do have a bad habit of stoping in for a bite when I feel lonely or depressed. Lately, I have been trying to pop into curves or online with you all. Thank you all for the ideas. I am definately going to keep up the fight.

[TannsGranny 0]

I wouldn't go self-pay just yet. There are two good obesity lawyers that can help you on this. Go to either WWW.Obesitylawers.com or WWW.Obesitylaw.com . I think nearly all insurance companies deny the first time around. And there's no legal standing for the supervised weightloss being a pre-requisite, at least not any that I have read about. Hope you win soon!

[lauri 0]

Thank you for the help. I am going to give them a looksee! Go! Fight! Let's Win!