Oxford (Freedom) NYC

KarenB · May 8, 2007

Apparently they do this all the time. I'm meeting someone tonite @ his support group who has Oxford Freedom...the submitted the paperwork & she was approved in 4 days. Since I have all these weird (6 degrees of separation) relationships with this doc., I HAVE A SURGERY DATE OF JUNE 18TH. It's the day after my b'd, so one last meal and all that stuff. Of course if insurance denies it, it will have to be postponed.

He is not w/any insurance for reasons you stated, but he does get out of network approval & the patient's responsibility is $1000. The hospital is in-network & that will be covered; I checked.

I'll let you know more after tonight's meeting...thought, maybe it's different in N.Y.,

chickatee · May 14, 2007

woo hoooooooooooooo

KarenB · May 17, 2007

the meeting was great...process is what I outlined. Interesting comment my doctor made: It is against the law to deny WLS to a patient who meets the criteria of BMI 40 or over or 35 w/2 co-morbidies. Next time I see him I'll ask him if that's a NY state law or USA law.

Little did I know until I called on another matter today that his office has already submitted their request for authorization to my Oxford. Keeping fingers & toes crossed...

Karen

Alexandra · May 17, 2007

the meeting was great...process is what I outlined. Interesting comment my doctor made: It is against the law to deny WLS to a patient who meets the criteria of BMI 40 or over or 35 w/2 co-morbidies. Next time I see him I'll ask him if that's a NY state law or USA law.
Little did I know until I called on another matter today that his office has already submitted their request for authorization to my Oxford. Keeping fingers & toes crossed...

Karen

Fingers AND toes crossed!!

The doctor might be thinking of "against medical guidelines" rather than against the law. Insurers aren't in the business of providing care to patients; if coverage for bariatric surgery isn't in the contract, there's no law against denying coverage. But he is right in that IF bariatric surgery is covered, and IF the patient qualifies, then legal pressure can indeed be brought to bear to force the insurer to cover it. That's how I got it done. :biggrin1:

KarenB · May 27, 2007

My band-removal/RNY was approved on Thursday. It took a little over a week w/Oxford Freedom. Stephanie in Dr. Garber's office was very diligent with following up with them, and believe me, I was diligent inbugging her every day! She told me that Oxford Freedom is one of the easier companies to deal with (for lapbands as well)--don't know if it's the same in every state (I'm in NY).

Karen

Alexandra · May 27, 2007

Hey, Karen, what's your BMI now? I don't know if you saw my post elsewhere, but the request for precert for my re-banding surgery was denied based on my low BMI. Did that issue pop up for you? Or is the fact that you're having it all done at once mean it doesn't matter?

KarenB · May 28, 2007

Hey Alex. I know we PM'd, but I thought this might of interest to someone else. My BMI has not reached 40 again (yet) but I was prepared to do anything to get it back up there if I had to. I told you I would have gone into the office w/those terry-cloth covered ankle weights on to get weighed again if I had been rejected. Luckily, because of the high BP, I was approved. I really think that sometimes if the person on the doc's office speaks to the same person at an insurance company frequently, it makes it a little smoother.

To answer your question, my BMI when first weighed was 37, now it's 38, and I do think that the removal due to an esoph. condition was a help too.

Karen

Dee Martin · May 30, 2007

So guys I would like to give you an update on Oxfords deal on BMI below 40 (35-39.9). You must have one of the following 4 problems or they will not approve you. :faint:They are as follows:

Weight related disabling joint disease; or
Pulmonary hypertension of obesity; or
Coronary artery disease; or
Insulin-resistant type II diabetes

Good thing about them is if yout BMI is 40 or greater it is very easy to get approved and you don't need medically supervised diets. I am going to have to gain 10-15 lbs to get my BMI to 40. It's worth it in the long run right?!?! :clap2:

Alexandra · May 30, 2007

That's a very clear-cut list. I'm encouraged by Karen's approval for what amounts to a revision, even though her BMI is under 40, but still there's no sure thing.

My doctor's office told me yesterday that they are filing an expedited appeal and expect a medical review to take place today. I asked what the experience was with this, and the answer was that she's never filed an appeal to have a band replaced. In this practice when bands have been removed it's always been for people who had been unsuccessful losing weight and therefore still qualified for replacement or revision. She didn't know if my lower BMI would completely prevent approval or not. :confused:

Dee Martin · May 30, 2007

I am sure there are different considerations for people who are getting a different procedure done or re-banded b/c of lap-band malfunctions. I have never had a surgery so those are guidelines for me. But Karan stated she had high blood pressure which is one of the four problems. Does slippage happen often guys? Do they know what causes it?

KarenB · May 31, 2007

Pulmonary Hypertension is different than plain old Hypertension & I was still approved. Re: slippage, please keep in mind there are plenty of happy, healthy bandsters who don't post here, so don't use this site as your whole basis for judging how often slippage occurs. If you do a search on "slipppage" or "slipped band" here, you will find plenty of info!

18 days and 4 hours till my procedure, but who's counting?

Karen