Medicaid Hell but didn't stop fighting

[Vivanew_Dani 6]

Hi everyone,

If anyone is in the process of getting approved you have to read this!!!!

I have medicaid, United Health Care Community Plan, all I have to say DON'T TAKE NO FOR AN ANSWER!!!!

Background: I'm 5'8, I had a lap-band in 2008 in the USA (had great insurance at the time, all paid, got approved in less than 30 days) at 267lbs, lost about 140lbs but used to binge and purge a lot so the band slipped, I had it removed. Gained some weight back about 60lbs, so I panic went to Mexico (did not qualify for the insurance in the USA to pay) and had a gastric plication done where they fold the stomach. Didn't really work surgery is rarely performed in the USA and not FDA approved, only lost 10lbs after that starting gaining weight again. When I reached 225lbs I started looking at having my 3rd surgery, since I made my mind I kept gaining more weight.

Decided this is what I wanted so started preparing for my gastric sleeve at 245lbs and got diagnosed with sleep apnea. Did all my nutritionists visits, all medical clearance sent to the insurance (Medicaid) United Health Care Community Plan. Sure enough insurance denied because my BMI was under 40, I appealed it twice, the second time they denied saying I had 2 previous surgery that were not successful and this was not medically necessary..... So, I carefully read the letter and followed what the next steps would be, like requesting a fair hearing which I found out no one ever does and sending to an external reviewer, also very few people do this.

At the same time I request an external review performed by ipro, wrote a heart felt letter by hand and sent in. In two weeks they had the insurance decision overturned.

But the fight wasn't done, the overturn came only 11 days before surgery, it took another 7 days for the insurance to accept the letter, they kept saying they didn't receive it, so I called the insurance about 4-5 times a day, called the external reviewer which were very helpful. Only 4 days before surgery it was actually approved. I kept begging the surgical team not to cancel my date.

In the mean time I kept going to my nutritionists appointments, I even went to my pre-op evaluation at the hospital even before having the approval, so since the approval came in last minute, if I had waited the blood work would not have been ready on time.

Now with the fair hearing, it was going to be my backup, I have a court date for August 3rd, but will call to cancel since it was overturned. I had even contacted a free state lawyer to help me fight in case the external review and fair hearing did not side with me.

I'm an accountant and future law student, will help anyone that is having issues with insurance, will help fill out paperwork, I would have loved to get some advice from someone that had been through this before.

Surgery is July 25th, 2016. I'm very excited, I already had the taste of what "skinny" is like and can't wait to try it again.

The insurance coordinator said: "Girl, you if you don't fight for yourself, no one else will" I did, I won. Already a winner, now ready to be a loser LOL.... losing the weight only....

[stephanie0305 0]

I know this is an older post but I also have United healthcare community plan in nj, I'm so worried I won't be approved even tho I had the Lap band surgery about 6years ago but had to have my port removed due to MRSA after I had my csection...I'm trying to go out of network to my original surgeon, I have a feeling it's going to be hard for them to to get to cover it