Question:
Can they do this??
I first submitted my packet in October and got denied because...in their words "there must be a history and documentation submitted.... IN AT LEAST 3 PROFESSIONALLY SUPERVISED WEIGHT LOSS PROGRAMS FOR A MINIMUM PERIOD OF 12 WEEKS IN EACH PROGRAM AT LEAST ONE OF THE PROGRAMS SHOULD HAVE BEEN COMPLETED WITHIN THE PREVIOUS 12 MONTHS... ok.. so now I get my 2nd denial letter and it now says........active participation and reasonable compliance with at least 2 professionally supervised wt loss frograms for a min of 26 weeks in each program..with one in the previous 12 months.....What in the heck??? I am furious.. also.. I don't think they read my whole file..because they said I needed support documentation from medical..surgical..psychiatric and nutritrional expertise..etc.. I HAD ALL OF THAT AT THE FIRST SUBMITTAL!! PLEASE HELP MEEEEEEEEEE!! — chris S. (posted on May 13, 2003)
May 13, 2003
Hi Chris. If it were me, I would get on the phone to those people and be
nice twice and then get loud. That's my motto when dealing with insurance
people. I would also start working my way to the top. The higher up you
go, the more reasonable they sometimes get -- especially if you indicate
that it may be time to get people higher than them involved. You can also
request that it go to their medical review board or whatever they have in
place. Of course, since you've already been nice twice, it's time to get
loud now! This is important for you and your life and you need to make
these people understand that! Oooooh, sometimes insurance companies just
aren't worth the hassle. Good luck!
— Cheryl M.
May 13, 2003
Hi Chris, what insurance company do you have?
— RACHEL A.
May 13, 2003
with my surgeons office, they deal with all of the paperwork, insurance
company, and any kind of denial letters. do you have to do it yourself or
could your surgeons office do it for you too? i know everyones insurance is
different, but check into it.
— Lynne W.
May 14, 2003
My ob-gyn is the one that suggested that I consider the gastric bypass
surgery. I had cysts sourounding my ovaries and I also had dysplacia. I
told him that my insurance would not cover it, he was surprised. I decided
to take the initiative and called him up to refer my to a surgeon. I
thought what is the worst, they can deny me. He wrote a letter for the
insurance stating that I was in serious danger of coming down with
diabetes, high blood pressure, and cancer (because of my family
background). Keep in mind that I was a very healthy 310 pound female. I
scheduled my appointment with the surgeon and went in for the initial
consultation, he said I was the perfect candidate because I was young and
healthy. That afternoon they submitted the paperwork to the insurance
before they left for the day. Well the next morning they had an answer at
the fax machine. I WAS APPROVED OVERNIGHT! They were shocked, they had
never seen that before. Well I send word around that I had been approved
and guess what three other females that I work with who had been denied
were fully remimbursed for what they had spent. Don't give up, keep
hagling them. Get your doctors to write very convincing letters stating
the risks and danger you are running. I'm one month post op and down
thirty pounds, I feel great!
— Melissa T.
May 14, 2003
Hi Chris...it sounds like they changed their criteria (perhaps as of Jan
1st 2003?) BUT, there may be a loophole in that you applied under the old
criteria. Look into this. You may have to retain legal help. So sorry
they are jerking you around...you sound really upset. I had to wait 14
months for Kaiser to approve and schedule me. But at least at about month
9 into my journey I KNEW I was approved, and it was just a matter of them
putting me on the schedule. Either way, extremely frustrating and
upsetting, I know. Keep us posted. Hugs, Joy
— [Deactivated Member]
May 14, 2003
IF YOUR ONLY MEANS OF HAVING WLS IS THE INS CO PAYING FOR IT, YOU DONT HAVE
MUCH CHOICE BUT TO COMPLY WITH WHAT THEY WANT. IT TOOK ME A YEAR & A
HALF BUT PERSISTANCE PAYS OFF. AETNA KEPT TELLING ME THE SAME THING, SO I
STARTED NEW DOCUMENTATION OF ALL THE THINGS THEY WANTED BUT CONT TO APPEAL.
I TOO FELF I ALREADY HAD DONE EVERYTHING THEY ASKED & HAD THE
DOCUMENTATION TO PROVE IT. I FINALLY RESUBMITTED *EVERYTHING* &
ACTUALLY HIGHTLIGHTED THE INFORMATION & PUT POST IT NOTES WITH WRITTEN
EXPLAINATIONS. I KNOW HOW FRUSTRATED YOU ARE BUT KEEP AT IT, PERSISTANCE
DOES PAY OFF.
— PATRICIA S.
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