Denied again.... [emoji853]

[reese711 8]

Initial appointment with surgeon was last august. I was told all insurance requirements at the first visit and completed all of them in a little over a month. They told me my insurance did not require the 6 month supervised diet and submitted my paperwork. It was denied because I did not have 6 months supervised diet and upper gi scope done. While they appealed it I just started the 6 months of visits and scheduled the upper gi series. My last appt with my pcp was the middle of feb and I was down 10 lbs from my initial appt. they submitted my paperwork again with both things they required in my initial denial and today I found out I was DENIED again. Because I am hypothyroid, because my upper gi series showed MILD reflux, and because I lost 10 lbs in my 6 month supervised diet they said I'm able to lose weight with exercise and diet. I am very annoyed, I politely said to the insurance rep this is a covered surgery under my insurance plan, I've done everything you asked from the las denial and you are still denying coverage. I'm confused.... they replied you are welcome to appeal. Ughhhhhhhhhhhhh! Frustrated.

[SummerShadow 27]

So sorry to hear that. How frustrating! May I ask which surgery you're trying to have? The reason I ask is that I've read on many medical sites that one of the 'co-morbities' that may be accepted AS a co-morbity was reflux. Also, when reading about the different types of surgeries it stated that lap band wasn't advised if someone has reflux and gastric bypass and sleeve actually HELP with reflux. This is all so confusing, really, isn't it?

[reese711 8]

Sleeve surgery..... my bmi is over 40 and I have hypertension. I've met all requirements and done everything they've asked. Now they want documentation that my obesity is not endocrine related and want my mild reflux treated..... which is weird cuz it's not bad enough to need treatment.... I'm waiting for my bariatric office to call me back with the next steps. I'm about to file a complaint with the state commissioner because this is a covered service and they are denying me for irrelevant reasons. Insurance is the most frustrating thing. Why I pay thousands of dollars a year for them to deny coverage over and over again.

[SummerShadow 27]

Okay, just did a bit more research. Bypass actually HELPS, and in some cases CURES reflux/GERD but that gastric sleeve, lap band... etc.. could make it worse or even cause it if you don't have it to begin with. So, guess I'll be changing my option to the only one I have left, which is bypass. I hope you can get some resolution with your situation. Has to be so frustrating.

[SummerShadow 27]

1 minute ago, reese711 said:

Sleeve surgery..... my bmi is over 40 and I have hypertension. I've met all requirements and done everything they've asked. Now they want documentation that my obesity is not endocrine related and want my mild reflux treated..... which is weird cuz it's not bad enough to need treatment.... I'm waiting for my bariatric office to call me back with the next steps. I'm about to file a complaint with the state commissioner because this is a covered service and they are denying me for irrelevant reasons. Insurance is the most frustrating thing. Why I pay thousands of dollars a year for them to deny coverage over and over again.

You may have seen my last reply by now, but it's likely due to the sleeve procedure having a very high risk in causing GERD/reflux in people who don't have it, and also making it much, much worse if you do have it, even when mild. Seems there's a corrective surgery that may have to be done if one develops reflux/GERD after the surgery, or if it becomes worse. Maybe bypass would be approved for you since you have mild reflux. I'm having to change my focus on that as well since I also have reflux.

[reese711 8]

I wondered about that, just wasn't super excited with the idea of multiple organs being manipulated in surgery. I was planning on asking how difficult it would be to switch surgeries after I've already submitted for approval....the surgeon did mention if reflux is bad bypass may be a better option.....

[SummerShadow 27]

17 minutes ago, reese711 said:

I wondered about that, just wasn't super excited with the idea of multiple organs being manipulated in surgery. I was planning on asking how difficult it would be to switch surgeries after I've already submitted for approval....the surgeon did mention if reflux is bad bypass may be a better option.....

I'm really new to this so not sure, but I think that the basic criteria is the same (BMI etc). I like the idea of the sleeve better as well, but since I do have reflux I'm sure they'd deny me for sleeve.

[GrrlAnn 177]

I think the insurance company wants to confirm that your thyroid isn't causing your weight issue. If the doctor can treat your thyroid medically, you may not need the surgery.

[SummerShadow 27]

2 minutes ago, GrrlAnn said:

I think the insurance company wants to confirm that your thyroid isn't causing your weight issue. If the doctor can treat your thyroid medically, you may not need the surgery.

Aaahhh... good point. Reflux is one thing, thyroid another. Wouldn't that be awesome, though, to be able to do it without surgery!?

[reese711 8]

I think the insurance company wants to confirm that your thyroid isn't causing your weight issue. If the doctor can treat your thyroid medically, you may not need the surgery.

I am on synthroid.....my last blood work showed very normal levels for my thyroid. It's been treated for more than a year now.

[SummerShadow 27]

A friend of mine just had RNY bypass and she has Hashimoto's. Is your doctor helping you sort this out? I hope?

[reese711 8]

I am waiting for the office supervisor to call me back.....of course she is out til Monday. Bummer

[SummerShadow 27]

Wow. I hate that. I'm waiting, and will over the weekend, JUST to get an appointment with my old PCP since the new one has staff that never answers the phone (just rings and rings). Always one the weekend, right? And like the waiting isn't long enough as it is. Keep the faith... and please let us know how things go!!!

[reese711 8]

One way or another my insurance is paying for this surgery. I meet every qualification they have. Sooner or later they will get sick of me and approve me.

[SummerShadow 27]

19 minutes ago, reese711 said:

One way or another my insurance is paying for this surgery. I meet every qualification they have. Sooner or later they will get sick of me and approve me.

lol Now THAT'S the spirit! I'm going to go toe to toe with my insurance company too, I'm betting.