Question:
How do I go around this wall?

I expected an insurance denial for WLS; but, a denial from my medical group for a referral? My PCP put in a referral 09-14 to see Dr. H. Lewis Smith in Whittier, CA because I had fulfilled the "known" requirements of medically supervised diets. I called her today and she told me that it was denied. She faxed me a portion of what they are to send me and this is the exact wording: Criteria for Gastric Bypass Consultation (the following criterial must be met prior to referring patient for gastric bypass consult) 1) Documented proof of failure of six diets with the previous 5 years, three must be medically supervised, 2) Significant Co-Morbidities and treatment of those diagnoses by the referring PCP for greater than 9 months, 3) BMI greater than 40 (I'm 5'6, 249 lbs), 4) Must be 100 lbs or more overweight for a period longer than 5 years, 5) must be between 19 & 61 years of age (I'm 40), 6) Verification of Health Plan that patient has a benefit for gastric bypass. I'm so upset right now that I don't know what to do? My PCP doesn't believe in WLS - she's the 2nd PCP I've seen and I've already switched medical groups within Healthnet twice. Any suggestions would be very much appreciated... Thank you!    — Peri B. (posted on September 21, 1999)

September 21, 1999
I think I have the answer you are searching for. I also went through the same problem. Until I beat them at their own game. You need to go about it backwards. First find the bariactric surgeon on your plan that you would like to have perform your surgery. Then set everything up through them and have them give you the name of a PCP in your plan that will have a more open view of weight loss surgery. Don't get upset or mad , just find your way around these insurance problems and you WILL suceed. Forget switching to yet another doctor without knowing before hand what their views of WLS are. Save yourself the time and effort. Good Luck and feel free to contact me if you need further info. Diane Domingeuz, Post-Op Fobi Pouch, Open RNY , Medial Bypass 150 cm, 9-15-99
   — Diane D.

September 21, 1999
Peri APPEAL AND APPEAL I had the same problem, I was denied by my medical group, but I hired Walt Lindstrom(an attorney from San Diego) He wrote the most impressive letter to my insurance appealing the groups decision. I have jumped through all the hoops that was requested of me. I even had to go out of plan because there are not any surgeons in my plan that do this surgery. I am waiting for the final authorization and I have a tentative surgery date of Dec.1st So the main thing is not to accept fight and appeal. If you would like to email me personally I will be happy to give you this attorney's name and number. His fee is quite reasonable also. Good luck with what ever you decide. My email address is [email protected] feel free to write any time. By the way I am from Sacramento, CA. I do not know where Yorba Linda is please enlighten me.
   — Lorraine H.