Can anyone help with Pacificare HMO appeals process

[Guest tntplust]

Hello everyone,

I was hoping someone might help me get started on an appeal. I am a 400lbs 5'9 36 year old male who would like to get a Lapband. I have been refered by my primary physcian to an obesity specialist who does both Lapband and Gastric Bypass. The obesity clinic has been given the approval to do the Gastric Bybass on me. When I inquired about getting the lapband instead the Obestiy Clinic Insurance representative told me that Pacificare HMO does not cover that procedure. I had previously called the insurance company and talked to a representative who said that while the lapband was not on the list currently that I should have the surgeon submit the request and see what would happen. I have told this to the insurance rep at the obesity clinic but she is a stone wall. She simply states that it is not offered. I have asked her if she would help me with and appeal and at first she seemed like she would be helpful but then the ball would just get dropped. Today I received my packet to go ahead with the Gastric Bypass! Even though I told the obesity clinic that I wanted to appeal for the Lapband they already have me scheduled for surgery for the Gastric Bypass. Honestly I dont feel they have my best interest. I feel that since they have approval for bypass they don't want to rock the boat and help me get what I really want the Lapband. This has been a long fight for me to get my primary physician to recommend to to this specialist (1 year). I don't really want to start this procedure all over again with a new primary and a new specialist.

[porclndoll 0]

I am not Banded yet...but I am working on it....The only thing that stood out in my mind when reading your post is that you don't feel like they have your best interests in mind.. I certainly would not proceed with a doctor or clinic that I didn't feel comfortable with. Get the procedure that you want...even if it means starting over with someone else. Perhaps you wouldnt have to start all the way over...like with pre surgical requirements like the psych consult, Upper Gi...if you did all that all ready. The new clinic could obtain copies of prior tests with your permission. I know that this hasn't really given you much help, but maybe it has given you something to think about.

Good luck to you!