Question:
I was denied now what?
After waiting since Nov. 19,2001 and jumping all the hoops, BC/BS of Fl has denied my surgery---MyBMI is 41--I have uncontrollable diabetes and hypertension. The nurse that reviewed my case said I did not prove I was obese more than 2 years---we sent the last 3 years of medical records-then she said that my weight fluctuated--duh---I was on a supervised diet for 2 yrs to qualify--sure my weight fluctuated--Right now I am so low---I was so set to be having this surgery soon---we are appealing this decision--and my arguement is this---Insurance will pay if I am a drunk and want to sober up----it will pay if I am on drugs and need rehab---why won't it pay for me to gain my life back and live a quality of life????????? — Linda L. (posted on March 19, 2002)
March 19, 2002
Hi... Don't give up quite yet. If this is your first submission its not
unusual to be denied if your BMI is on the lower side. Talk with your PCP,
your endocrinologist and any other physicians you use with your
comorbidities and get good letters of necessity. Your PCP should be able
to write a letter indicating your history of obesity if it is lengthy. If
it is not a lengthy time and you have not been obese for long your struggle
might be harder though not impossible. As far as uncontrollable comorbids:
It is many times the case that diabetes, hypertension and other things are
out of control. Could be that the combination of meds don't work any
longer, could be you've gone to a new level, could be a mix of diet, lack
of exercise, etc. Not knowing if you are Type 1 or Type 2 Diabetic its
harder to confirm that. But it is not unusual for Type 1's to stay out of
control through no fault of your own. Type 2 you really need to watch your
carbs, insulin, exercise level, etc. But try not to get hung up on the WHY
it isn't in control. So for now, talk with your docs and lay out your plan
of attack and keep fighting. My best to you.
— AJC750
March 19, 2002
First of all, know that what I might say will probably upset the first
poster but so be it. I have found that, at times, people can come across
so negative and ugly in here and I'm sure they probably don't mean to do it
intentionally - I feel like your statement of "right now I am so
low" should give the trigger that you don't need more added grief or
negative comments - we're here to support, right? I have absolutely felt
like saying a few things in answering Q/A or commenting but always tried to
remember the good old rule that my mom told me so long ago - if you can't
say anything nice, do not say anything at all. Know what I mean? With
that, know that I've received really crummy email from some of the people
at the WLS sight - but the majority of them...most of them are awesome,
kind individual who are here to help balance you when things go chaotic or
who will tell you openly of their experience. With that said, I wanted to
tell you I can absolutely relate to you feeling so overwhelmed with things
when something goes sideways from the way we believe they should be. Been
there, done that - probably most of the people dealing with this problem
has been...whether they admit or not. The feeling of desperation at times
seems to come hand in hand with pre-op patients - I am one too and I'm
there more often than not.
I wanted to also say this: the response from your insurance company did
not sound solid - it's not as though there is an exclusion in your policy
so don't hesitate to move forward. Do you want some of my letters and
information that I took to my own PCP in going through all of the medical
conditions that were at least somewhat caused by my morbid/super obesity?
I've only been with this doctor since 1999 and I've been on again / off
again fighting this my entire life. It's up to us to supply more history.
I'll be glad to send you the novels of letters that I've submitted. Don't
give up..it's very common to be denied on your first or second try but like
I said, it didn't sound real solid. Hang in there - write if you'd like
and I'll send you what I have...maybe you can put it to use in your own
life.
Bright blessings and try to keep your chin up...the fight has only just
begun :)!!
— Lisa J.
March 19, 2002
Linda, I just wanted to say PLEASE don't feel that having uncontrolled
conditions is your fault. That first response was incredibly cold and
UNEDUCATED to say the least. It reminds me of someone saying we are
morbidly obese because we're lazy and its all our fault.
Technically ya, eat less, exercise more and you'll be thin. Realistic? I
don't think so, not for me and not for most of us on this site. I can tell
you my diabetes is uncontrolled and its not for lack of trying! At well
over 100 units a day and a strict diet my sugars are NOT controlled. I'm
extremely insulin resistant and unable to tolerate any of the oral meds.
Yes it sucks but I would never say its my fault. I AM doing all I should
and struggle every day just to, not only control my sugars, but also to try
& maintain my 300+ weight! Chin up and Good Luck on your appeal!
— Shelly S.
March 19, 2002
Thanks for your positive responses---my hypertension is under control---its
the diabetes--I am insulin resistant--I have tried meds and diets--massive
doses of insulin to no avail---my PCP and specialist have not found an
answer for me--I have been obese all my life--I weighed 30+ pounds at 1
year of age---I came in lookig for support from my team mates--and those of
you that offered support and understanding---thank you
— Linda L.
March 19, 2002
Have to put in my 2 cents worth. First, Ava Lee, how do you know you
couldn't get your diabetes in control if you refused to take insulin? I
have to try to dispell a myth here. The needles used on insulin syringes
are very small and are coated with a substance which makes them slide
easily into the skin. Ninety-nine times out of 100, I don't even feel
them. I have been taking insulin for 36 years and if the only thing I had
to do to control my diabetes was to take those daily shots, it would be a
piece of cake, pun intended.<p>Andrea, I don't know where you got the
idea that Type I is hard to control. Most of the people I know with Type I
are in excellent control. When you don't make any insulin, your body isn't
insulin resistance. Most of us test our blood sugar 4-6 times a day and
through careful record-keeping have learned how to balance our food,
exercise and insulin to keep us in good control. I am MO, but my diabetes
is in good control. After 36 years, I have only some peripheral
neuropathy, no eye problems and no kidney problems.<p>Finally to the
original poster, please keep trying. Your insulin resistance is almost
certainly due to your excess weight. It should be a reason to have
surgery. Don't give up yet.
— garw
March 19, 2002
Gar, just as we disagree about many diabetic details it IS possible to be a
hard to control type ONE. My step sister is type one and a brittle
diabetic. Her sugars bounce all over the place. On many meds she is MO, or
close too it, highly unusual for a type one. Docs say its weight gain from
insulin. Plagued by highs and lows, at 45 she is hanging on life. Her twin
died at 40 from diabetic related health problems. Diabetes is such a
terrible disease. For many MO WLS fixes diabetes and saves lives.
— bob-haller
March 19, 2002
It sounds more like the nurses misinterpretation of the guidelines. If the
appeal does not work, you may need a lawyer. Her reasons are not
acceptable and are contrary to BC/BS practices.
— faybay
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