it's just getting to me........

Hi California friends,
it's been a good while since i've been here.
been going through some bouts of depression
because i keep getting  denid for surgery (3 times since dec.)

i want this so bad, and each time they say NO i feel myself slip......

at the same time i'm trying so hard to stay with my diet guidlines
get exercise, focus on positives.........

i just wanted to post hoping there are others out there like me
who have gone through this and did get to have surgery!!

and for the others who have done an  awesome job since their surgery
i love reading the stories and see pictures of all of you
who are no longer trapped inside their bodies!!!
xo
sydney

Sydney,
I just wanted to say that its awsome that your making healthy changes and still trying even though insurance has denied you. Keep fighting they say the squeeky wheel gets the oil right? well I really wish you the best and hope that they will approve you if you are still trying to get it.
GOOD LUCK
Robin

What are the "specific reasons" you've been given for the denials? Is there a written exclusion for weight loss surgery? Are you with an HMO, PPO? Is you or your husband’s  plan self-funded through an employer?

Details might help us help you.

Rock

thanks Robin..still trying!

thanks too Rock,  the first time was not enough info. which
i guess there was, but, insurance companys do that??
the 2nd and 3rd was in March 2007 my BMI fell below 40 by .4
and when they asked for more weight info i also fell below 40 in march 2006
 we sent them 260 wieghins 5 years worth, and they found those 2 times......


i have Blue Cross of Alabama (not sure why Alabama since i live in calif.)
i have no husband....i'm sure if i did he'd have better insurance ..LOL

 still hoping!
sydney

Firstly, call and write via certified mail if need be and demand  ALL THE SPECIFICS  on those denials. 

Second, call and write via certified mail if need be -and insist on a FULL description of ALL their WLS requirements and what they cover and what they don't cover and the reasoning given as to why.  

If your now above a BMI of 40 than you already meet the national standards without needing to demonstrate any serious comorbities.

Is the plan self-funded or an HMO or PPO? 

Rock 

I have a PPO,

the biggest requirement is to have a BMI higher than 40 witn no co-morib medical problems.
for 3 years in a row......so on those 2 different weigh ins   (3/06 and 3/07 ) i dropped below
i have to start my 3 years over again. so that would mean i need to wait till 3/2010 to quilify

I'm really healthy, i run marathons, i work out, hike, walk to and from work (2 miles)
i'm just big.
4'11'' 230 pounds
I have been this way me whole life,  when i was alot younger
i exercised myself to death to lose weight......way harder to do now
and add menopause to that...... i'm thrilled when i can lose a  1/2  a pound!!

i am still trying, the Dr's office has been really healpful, i'm thinking i need to
call the office to see if i need to start some sort of campain along with
what they are doing?

thanks everyone
sydney

http://www.hrh.org/cag/agresrce.html

Resources To Help You Resolve Your Health
Care Problem in California



If you have a problem with your health plan, the rights you have depend on the type of plan you are in and who pays for your coverage.
If you are in any kind of health maintenance organization or HMO, whether through your job, through Medicare or Medi-Cal, or if you have coverage through Blue Cross or Blue Shield, you can contact the California Department of Managed Health Care (DMHC). The DMHC oversees health plans. However, unless your problem is an emergency, the DMHC requires that you work with your health plan to resolve your problem for at least 30 days before the DMHC will take your complaint.
California Department of Manged Health Care (DMHC)

HMO Helpline
(888) 466-2219 (toll free)
If you are in a preferred provider organization or PPO, or most other types of plans, the California Department of Insurance regulates these programs.

California Department of Insurance (DOI)
(800) 927-4357 (toll free)

If you are on Medicare, you may contact the Health Insurance Counseling and Advocacy Program (HICAP). HICAP provides objective information regarding consumers' rights in Medicare. Other resources for Medicare beneficiaries include:
? The regional office of Health Care Financing Administration (HCFA), that regulates Medicare programs; and
? California Medical Review, Inc. (CMRI), to report a concern about the quality of care you have already received

Health Insurance Counseling and Advocacy Program (HICAP)
(800) 434-0222 (toll free)
Centers for Medicare & Medicaid Services (CMS) 
(415) 744-3617
California Medical Review, Inc. (CMRI)
If you are enrolled in a Medi-Cal HMO, your additional resources include:
? Health Care Options if you have a problem with joining or leaving a health or dental plan.
? The California Department of Health Services Medi-Cal Managed Care Ombudsman to help you resolve a problem with your health plan.
? Your eligibility worker, whose name and telephone number appear on notices you get from the county, if you are having a problem with your Medi-Cal eligibility.

Action Tip You also have the right to request a state hearing to have an independent judge decide what is right in your case.
Health Care Options Helpline
(800) 430-4263 (toll free)

California Department of Health Services
Medi-Cal Managed Care Ombudsman
(888) 452-8609 (toll free)
California Dept. of Social Services
State Hearings
(800) 952-5253 (toll free)


If you have private coverage through your employer or union, your benefits may be managed or "administered" by another company whose name might sound like an insurance company. Employer sponsored plans are also called "ERISA" plans, meaning they are governed by the federal Employee Retirement Income Security Act. Your rights to appeal may be different. Ask your benefits administrator or union representative for assistance and an explanation of the rules that apply. You also may contact the federal Department of Labor (DOL), which regulates employer-sponsored plans. In general, DOL does not provide any assistance to individuals. However, DOL will track your complaint to see if there is a pattern of problems with a particular employer-sponsored plan.
U.S. Department of Labor (DOL)
(415) 975-4600

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Rock

You're not alone, Sydney.  I remember I had a friend who put coins in her pocket for the weigh in because of this.   

Talk to your surgeon and see what else you can do.  Also... check the boards, you will find what others have done in these situations. 

You'll get it! 

Do you have any co-morbidities?  Let them know how the weight exasperates these.

I have Blue Cross (Anthem, now) and I was approved when they were more lenient.

Good Luck!!!

Don't give up Sydney!!!!
There is a guy in my support group up here that went round and round for 3-4 years before he finally got it! And he is doing great now!!! So don't give up! It is worth all the hard work!!! I promise it is! :)
Hugs,
Gavin

Sydney there are a number of people here who have been denied over and over again and have gone on to have wls approved by their insurance.

If I were you, I would follow Rock's advise...he really knows what he is talking about and also you could have the option of hiring an obesity attorney from this site to fight for you!

Try really hard to keep your chin up...I really do feel for you....stick around too so we can support you through this....you do not have to go this alone!