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

HI SWEETIE

SO GOOD TO SEE YOU. CAN'T WAIT TO SEE A NEW AVITAR PICTURE OF YOU. OR EVEN A PICTURE IN YOUR PROFILE.

MUCH LOVE TO YOU MY FRIEND.  
HAVE A WONDERFUL AFTERNOON AND EVENING

Hi my Dear friend,
  so good to see you too- my cord on my camera got rolled on by my desk chair and ruined it- so I have to go to Kodak and get a new cord so I can download my new pics!  BB10  2nite- geesh, Keesha made a really bad decision last night!!!!
                                 love ya, Chris

Hi missy Chris

Keesha made a big mistake but no bb tonight it's tomoorow night. they have changed the nights to thursday sunday and tuesday.

I guess they got complanits about it being all together and nothing to watch at the end of the week.

love ya

Jeni,

I am soooo sorry to hear about your battle with the insurance.  Shells is correct, the insurance companies just want people to get discouraged and quit, but hang in there it is worth it.  Have you or could you change insurance companies?  A few years back I had a total knee replacement (TKR) and got a bone infection and the doctor that did the surgery would not redo the TKR and my insurance group with not do anything about it, go figure?  We then had to wait until open enrollment and change insurance providers. Then with the new insurance providers they took care of things.   Hang in there!!!!!   Michele   

Thanks Michele,
i did contact Obesity Law and they say that I qualify for an apeal through Lap Band free with all of the information I gave them.  I just need my Surgeon's office to agree.  Hopefully they will.
Thanks!  Jeni

Hi Jeni... I am soooo sorry to hear about all that you are going through but I truly believe where there is a will there is a way.   You truly have the will.  Don't give up.   I'm saying many prayers for you.   Keep us posted. 

Repeat after me...I AM GOING TO HAVE THIS SURGERY....I AM GOING TO HAVE THIS SURGERY...I AM GOING TO HAVE THIS SURGERY!!!

Jeni...you are discouraged and rightfully so....but you do what you have to do and that is fight for your right to have this surgery. Once you get the law after them, you watch their tune changed. I am praying and sending all the good vibes there are...and the insurance company is going to get them some whop ass served up for them!!!!

And listen here Missy....I am sure in no way shape or form are you a burden of any kind to your hubby! He loves you Jeni and only wants what is best for you and if that means more dinero...then sobeit....you are worth it!

  

 What a load of bull!  They absolutely cannot require a treatment as a condition to other treatment and then say the required treatment is not covered.  THis girl just does not know what she is talking about.  You have a denial, you had peer review and got another denial.  Now appeal to the actual healthplan, not the IPA or PMG.  If you get denied there yet meet the NIH guidelines for WLS you will winn at DMHC, if you have to go that far.  Make an appointment with the nut. anyway and then appeal that too if they deny paying.  Get it in writing that they said you need to see the nut. for 6 months as a condition for treating your MO.  You can win this and get it done.  It will not be without frustration and delay but no doubt they are playing to make it hard to get you to give up and go away.  i works for alot of people, that's why they keep doing it,  Just make up your mind that it is not going to happen to you.  Once they realize that you wont just go away and see you armed with the resources to support that you are right and they are not going to win, they will probably cave.  My HMO did, it took from mid Feb to late May 08.  Hang in there. 

So, what exactly is the reason they say the WLS is not medically necessary for you.  You dont meet their criteria for the 6 month diet?

this is what the letter stated.........  I did 6 months of Weigh****chers which they said was accepted......now they came back with this..........

Dear Doctor or Provider
This letter is written notification that benefits have been denied as desoilbed below.
Our review determined that service 43770 (gaslric bypass) are/is not medically necessary in accordance with the Medical Policy based on the information provided.
The clinical basis for this determination is as follows:
iThere is no historical medical record documentation of 6 months of a clinically supervised weight loss program (including exercise counseting, lifestyle changes, and behavior modifications)
The source of screening criteria utilized as guidelines in making Ibis determination was Blue Cross and Blue Shield of Illinois Medical Policy guidelines, which are developed by Blue Cross and Blue Shield Medical Division. These policies take into consideration views of the state and national medical communities, the guidelines and practices of Medicare, Medicaid, or other government financed programs, and peer review lIterature.