Question:
Does anyone have info on how to beat denial from PacificareHmo? San Mateo County

Ihave been denied my consultation to see the WLS doctor. I have a BMI of 47.9. I also have hypertension that my medication is not controlling very well. I also have 4 injured disks in my neck and cannot exercise very well. Plus I have tried many weightloss gimics etc. I keep getting bigger and bigger. Pacificare says I need to have Coronary disease, sleep apnea, diabetes. Help I don't want any of those things. I snore very loudly could that be sleep apnea? Any tips on how to deal with denial from Pacificare? THANKS!!!! Janelle    — JANELLE S. (posted on September 16, 2000)

September 16, 2000
It sounds like you may possibly have a Sleep apena.. I would have a Sleep study done... It maybe your answer...
   — Michael (pokie) F.

September 18, 2000
Get a sleep study done. Tell your doctor you are snoring and not getting rest and somtimes awake gasping for air. If you are that much over weight you are likley to have at least some apnea.
   — MARK N.

December 1, 2000
I have pacific care.. the claws in my coverage booklet says it will cover it if you are 100lbs or 40bmi ( meet the nih gude lines .. witch i have looked up) and are ref. by your pcp please e-mail me direct... [email protected]... I was also looking at dr, in san Mateo... lets see if we can help each other... thankyou Lisa:-)
   — Lisa P.

December 2, 2000
I am insured by PacifiCare HMO. My pre-op BMI was only 38, but I had hypertension (like yours, poorly controlled by medication), chronic esophagitis (from GERD), and some other less serious co-morbidities. I also had a very grave family history (stroke, diabetes, heart disease). I asked my newly assigned PCP for a surgical referral the first time I saw her, in June 2000. The consult was in August, I was approved within two weeks, and had an open RNY (distal) on October 12. PacifiCare's policy states that they cover WLS in full for patients who meet the National Institutes of Health guidelines, that is, with a BMI of 40 or greater OR with BMIs between 35 and 40 with serious co-morbidities. If your PCP won't refer you, call the office of the bariatric surgeon of your choice and ask which PacifiCare PCPs refer the most patients, then change PCPs. If you've been referred for surgery and accepted by the surgeon as a suitable patient, file an appeal. The PacifiCare policy is unequivocal and you appear to qualify.
   — Linda B.

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