The Peer Review didn't go well...............

The medical director finally called my WL surgeon and they had the peer review on my case.  They would not budge.  The doc even told them that with their policy they make it impossible to get approval.  They said that I need to go see a nutrionist for 6 months and have them document my exercise as well. 
Well guess what???  I just called to get a provider for the nutritionist and she says my policy does not cover this, unless I have some other medical reason to go.  So I asked her if my doc refers me because of my high cholesteral and pre-diabetes would it cover then? and she said it would still not count as part of my requirements for approval of WLS....  So I guess I'm screwed!!!  I am not going to put more of a financial burden on my husband....
Jeni

JENI

THIS HAS GOT TO BE THE CRAZIEST, STUPID, MIXED UP MESS I HAVE SEEN YET. BUT DON'T GIVE IN OR GIVE UP. THERE ARE LAWYERS OUT THERE FOR JUST THIS REASON. I'M NOT SURE IF WAS MONICA OR WHO, BUT I KNOW THERE ARE A FEW PEOPLE THAT HAVE HAD PROBLEMS OF THIS MATTER AND FOUGHT AND WON. DON'T .. REPEAT DON'T GIVE UP. YOU CAN DO THIS WITH OUT PUTTING A FURTHER MONEY BURDEN ON HUBBY. BESIDES IF YOU DON'T GET THIS SURGERY YOUR GONNA COST HIM MORE IN THE LONG RUN WITH HEALTH PROBLEMS... I KNOW THEIR IS SOMEONE OUT HERE THAT CAN HELP YOU.

DON'T GIVE UP OR GIVE IN SWEETHEART AND DON'T GET DOWN. IT SEEMS LIKE THE BRASS RING IS FAR AWAY BUT IT REALLY ISN'T.

WERE HERE FOR YOU FOR AS MUCH SUPPORT AS YOU NEED AND I'M SURE THOSE THAT HAVE HAD TO GO THE LAWYER ROUTE WILL BE MORE THEN HAPPY TO HELP YOU OUT AND GIVE YOU THEIR KNOWLEDGE ON HOW TO GO ABOUT IT.

PLEASE PLEASE PLEASE DON'T GET SAD GET MAD AND FIGHT.

LOVE YA BUNCHES MY FRIEND.

Thanks Jodi..........
I'm trying to stay positive but it is wearing on me I must admit.
I'm feeling really depressed about all of this.  Hopefully Obesity Law will be able to help me out with the appeal.
Thanks for all of your support!
Jeni

I'm so sorry Jeni that this isn't going your way, but there HAS to be another way, right?  I'm thinking of you.  Hang in there!

Thanks Crysti....I'm trying!!!

WHAT?!?!?!

That doesn't make any sense, how does seeing a nutritionist for cholesterol and pre-diabetes not count towards seeing one for 6 months for surgical clearance? That does not sound right to me...what exactly qualifies it as being good enough to count against the requirement?

Have you contacted the Department of Managed HealthCare (http://www.dmhc.ca.gov/) ? I would get together all the documentation of everything you have been through for them and then file an appeal (I think its a request for an independant medical review) with them....at the least it can't hurt to try.

Its www.obesitylaw.com, the lawyers who specialize in this stuff. You might want to check them out too, I BELIEVE they will review your stuff and tell you if you have a good case for free or cheap....go to the website and look around.

Do not let this insurance company beat you down, this is exactly what they want, people to get discouraged and quit! You need and deserve this surgery to improve your quality (and quantity!!!) of life, don't let them tell you otherwise!!!


Shells

  SHELLS       I KNEW SOME ONE WOULD HAVE SOME INFORMATION FOR HER.

HAVE A WONDERFUL DAY

                      

Hi Shells,
Thanks for the advice.  I did contact Obesity law and they say that I qualify for the apeals program through Lap Band.  My doc is to request the application and we fill it all out and send everything to Obesity Law, they will go over all the documentation and then submit the apeal.
Wish me luck!!!
Jeni

Good!

Keep us posted!


Shells

Oh Jenni,
   I can imagine how defeated you must feel but like Jodi said there are people on the board ( they call themselves dragonslayers) and they have gotten legal help and won thier case.  Please keep some hope, I know they will post and tell you the steps to take.

                You will be a LOOSER............................................love, Chris R