Im so depressed, did anyone else get denied?

[j_war06 0]

My insurance denied my claim about 2 weeks ago, and we are going through appeals and I was just wanting to know if anyone else went through the same thing, and how did they win?:Bunny

[Alexandra 55]

Hi Jodie,

LOTS of people get denied, of course. Many win on appeal, but it all depends on your specific circumstances. In my case, my carrier denied me to the end based on their decision that the band was "experimental." But I was able to go to a third-party review board which overturned the denials and my carrier had to pay for surgery and everything else.

So it can be done! What is your carrier's reason for denial? If you don't have an exclusion for WLS just about everything else can be fought. If you want to give more specifics someone here might be able to share pertinent information.

[j_war06 0]

All I know is that my mom's company is self-insured and United Healthcare is their insurance provider. Basically they are telling me that the surgery is for cosmetic purposes only. We are preparing a case right now by going back to when all my problems with my knees and other problems developed and are adding up all the money that they have spent on doctors bills, tests, and medicines. I am having problems getting a letter from the orthopedic surgeon who actually recommended this surgery to me as a form of weight-loss, his receptionist has no idea what lap-band surgery is and is entirely rude everytime we call his office, and we never get to talk to him. I have a letter coming from my psychiatrist, TMJ specialist, and other orthopedic surgeons that I have visited. Basically if I do not have this surgery, and lose weight (quickly), my entire knees are going to collapse! I do not know what to do, I am so discouraged! I do not know how to go about an appeal, and am scared that I will have to live with this unbearable pain forever.

[Alexandra 55]

Jodie, what's your BMI? Do you have letters from your primary care physician and a bariatric surgeon? If you have a BMI of 35+ they can't claim that you want bariatric surgery for "cosmetic" reasons. There is a medical standard that says for people with a BMI of 35+ with comorbidities, or who have a BMI of 40+, bariatric surgery is considered medically necessary, period.

Do you meet those medical criteria?

[alatina 1]

I was denied and just didnt feel it was the route for me to fight them on it after 2x-I selfpaid-just wanted to get it done-good luck.

[j_war06 0]

We cannot afford to self-pay, period. My BMI is 41, but their problem is that I do not have co-morbid conditions (that are listed on those forms). I have serious knee and muscle issues. My primary care physician does not agree with the surgery, and will not write me a letter. My Lap-band surgeon already wrote a letter to them the first time to file the claim. I think the problem is the amount of filings they have had for this surgery, and because I am only 17. If I do not have this surgery, I may never be able walk any further than out my door into my car. I cannot even drive it when my knees hurt. I am so depressed.

[KRZYGIRLNSTL 0]

Basically if I do not have this surgery, and lose weight (quickly), my entire knees are going to collapse!.

Hi Jodie

I have knee problems too and they hurt really bad, how do i know when too much is too much. Basically...what are the signs that they could collapse. Curious to know. I need the surgery too because everytime i stand it feels like my knees are breaking.

[Alexandra 55]

Jodie, I think you should find another primary care doctor as soon as possible. If your BMI is over 40 you should easily be able to find a PCP and a surgeon who will recommend you for surgery. Your age might be a concern, but if there's a real medical case to be made your age shouldn't matter.

To be honest, your knee problems might indeed not have much to do with your weight--at your age, a BMI of 41 is probably not enough to do damage to your knees and losing weight might really not make much of a difference. I've had a BMI of 35-45 for most of my life and have never had any knee problems.

I'm not saying banding is not for you, but trying to play devil's advocate so you can argue other points. If I were you I'd concentrate more on the fact of morbid obesity and how all by itself it constitutes medical necessity. This is a standard measure in the medical community and your carrier can't simply decide it doesn't agree. (Assuming it doesn't exclude bariatric surgery, that is.)

[Guest Shelley]

Yes, I was denied with a BMI over 40. We went ahead and paid cash. I am only 6 days out and so far so good.

[j_war06 0]

My mom's company is self-insured and they have decided not to cover morbid obesity as a disease. We can not get weight-loss anything because the insurance will not cover it, so we have to list another problem that can be solved by the weight-loss products.

The doctor says that because of all the fat around the muscles and bones and stuff all over my body that it is extremely hard to read any of the test results. He does not think that there is a disease in there though anyway. He says that because my knees hyperextend and my bones are too small to support my weight. You probably do not hyperextend, that is why you may have never have had knee problems.

[j_war06 0]

How can you people afford to pay cash?

[Alexandra 55]

My mom's company is self-insured and they have decided not to cover morbid obesity as a disease.

This is truly unfortunate. I don't know what you can do about that except petition the company to change their policies, and that's a hard thing to accomplish.

Jodie, the cost of banding surgery is comparable to the cost of a low-end new car, and people afford that all the time. Loans, credit, selling things, payment plans are all ways people manage to afford something that means a better life for them.

From what you say it sounds like your doctor is not very caring. If banding is not in your immediate future, maybe it's time to concentrate on your legs. Get a new doctor and some new ideas! Perhaps physical therapy would help you learn new ways to move so as to minimize pain? Strengthening the muscles of the thighs is what I've always been told helps stabilize and support the knees.

Don't lose hope, Jodie. You shouldn't be in pain and I'm sure there are things besides weight-loss surgery that you can try. You're so young! In a couple of years you'll be on your own insurance and perhaps you'll have more options at that time.

[j_war06 0]

My doctor is extremely caring, she just lost a lot of weight naturally and not through surgery, but she is going to write me a letter anyway. I have been to every doctor from here to Houston and even in San Antonio (5 hours from here). I have done physical therapy about 3-4 times and it just makes them worse every time. We can not afford a surgery like this, at all. It is way out of budget and if my parents came up with the money I refuse to bankrupt them anymore than I already have. I have tried everything to make my knees quit hurting, I was even addicted to pain medicines at one time because of the pain. I hope this can happen soon, I just do not know what all is supposed to go in an appeal?

[alatina 1]

"How can you people afford to pay cash?"

Just knew I needed it done-went to Mexico for 9K-thats what my rainy day fund got used for-you are 17 so I can understand how you may not have an account for this type of thing.Good Luck-also you may want to look into financing-try this place...medicredit-1-800-963-6334

[Alexandra 55]

I hope this can happen soon, I just do not know what all is supposed to go in an appeal?

Appeals always have to address the specific reason for denial. If your mother's company's policy excludes weight loss surgery for everyone, your appeal would have to somehow convince them that they shouldn't apply that universal rule to you. And that's what I think would be hard to accomplish.

They've doubtless turned down other people who have tried to get bariatric surgery. Do you know if anyone has won an exception? If so, that person would be great to get advice from. But the hard truth is that companies who have deliberately excluded this or any other procedure from their self-funded plans have done so for considered reasons. They have no incentive to do your mother a favor, and no obligation either.

I can totally sympathize with not wanting to go into debt for this, Jodie. I didn't either, and wouldn't have. If I hadn't been able to beat my insurer on appeal I'd probably still be over 300 lbs right now. Debt is a serious load and not to be taken on lightly.

Your tone is distressing; I hate to think of you in so much pain with nowhere to turn.