PacifiCare thru San Diego County Employer

Hello, is there anyone out there that work for the County of San Diego that has Pacificare that has been approved for WLS? Here's the dilemma and it keeps coming up for me:

First I tried to get VSG got denied by the Managed Care department at UCSD saying it's not a covered benefit. Called and appealed with pacificare. Says WLS is a covered benefit but VSG is not "see surgeon to review other covered WLS." Ok so I seek RNY find out my surgeon does not do RNY and wants to give me Lap Band (he really doesn't think WLS is a covered benefit) but I don't want Lap Band. So seek help from Pacific Bariatric. Well I have a PCP at UCSD and he referred me for RNY it was denied today saying "WLS is not a covered benefit."

So now the hospital is saying the problem is with PacifiCare saying it's not a covered benefit, and then they want to give me the speak that sometimes insurance with different employers will approve the surgery. Well I stated that there are people with Pacificare that works for the County of San Diego that have been approved thru PacifiCare for WLS and maybe it's how you all are submitting the paperwork. Then she says we usually get Lap Band approved and I said I don't want Lap Band:

I was denied the request to seek RNY thru Pacific Bariatric because it is saying it's not a medical necessity. I am not understanding why this confusion is coming up because they are suggestion that this is something I am requesting not something that I need. Pacific Bariatric says that I need something from my PCP saying that this surgery is a medical necessity for me. I do not want the lap band because the revision rate is to high and there are more negative complications and failure rates with surgery than with the other weight loss surgeries. I have been dieting since I was 3 years old and I still have not been successful and this whole process is becoming quite discouraging. I can't give up because I know that it is something that has to be done in order for me to become healthy. I have tried the "normal tactics" and they have not worked. Please advise.

Is there anyone out there that can possibly help me? I am going to submit to the Insurance board as well.

I was approved for RNY thru Pacificare and I had a hell of time getting anything done or accuarate information from them. It was a nightmare.

Keep a notebook.

Everytime you call someone, ask for their name and their operator number if they can't give out their last name.

Ask them for a fax/printout of your policy that outlines what is covered for weight loss surgery including the criteria that qualifes. When I had my surgery two years ago it was a BMI above 35....or a BMI of 32 with at least 2 comorbidites.

Write down everything they say and include the date and time of who you spoke to and get their number to call them back if you need to. Its funny, most customer service folks will work a little harder for you if they know you are paying attention.

If all else fails...get an attorney. I had an AWESOME one help me win my approval. www.obesitylaw.com It's free to talk to them about your case and they are flexible and affordable if you choose to hire them.

 Don't give up!!

Do you have HMO or PPO?  That can make a difference in whether it's covered or not.  But don't stop fighting.  If you need to contact the attorney's Monica mentioned above.

I worked for PacifiCare at one time.  With HMO's the Medical Group is actually where denials and approvals are processed.  Medical Groups are paid what's known as capitation.  In other words, they are paid a set amount per patient, whether that patient is ever seen or not.  The hope is that the money coming in will be more than the patients being seen.  By doing this, the insurance company leaves the medical decisions up to the Medical Group.  I'm unsure how it works with PPO though.

When we were trying to get my husband's surgery, he was denied at every turn.  When you get a letter of denial in the mail, you have the right to then appeal that decision with the insurance company within 30 days.  You can ask for an expedited appeal, but by law, they have 30 days to make a determination on your appeal.  If the insurance company denies your appeal, you can still go higher.  There's a Managed Health Care Agency that you can appeal to also.  As Monica said, document EVERYTHING.  I actually still have every piece of documentation from our battle to get my husband's surgeries done.

I will tell you that we battled for more than 2 years for his Gastric Bypass, but we never gave up hope, and believe me it was tempting.  Don't give up and keep us posted.

I have Pacificare and I am with Bristol Park. When you do your appeal, let them know all the meds you are on and whether you have High Blood pressure, Heart Problems, Asthma need a c-pap machine at night.
I was denied in December 2007, I was having health problems. I have asthma, leaky valve in my heart from PHEN_PHEN, High Blood pressue and on C-Pap machine oh I was taken to hospital in Frebruary 2008 ended up having a-fib. Three weeks later, in the hospital, they decided to put a pace maker in. 55 years, went home appealed my denial letter. In the denial, I put everything down and then I said, You denied me, now I have a foregin object in my chest to regulate my heart, I need to have the WLS to survive.
Guess what, I had my surgery at UCLA September 2008, and couldn't be happier. You have to be your own advocate. Trust me, I know.
PM me if you want anymore information.
Lots of luck to you.
Hugs & Love,

Karen

To add to what Karen said about documenting everything, she's 100% correct.  We even went so far as to include the WLS surgeon's nekkid picture of my hubby.  Sounds bad, but we were desperate.

Hey there!

SD County Employee here.  Approved w/Pacific Care (RNY) on first try.  I went through Scripps Clinic and their bariatric program.  Now mind you, I'm 3 years out, and things could have changed but when I did it they were great.  They knew exactly what to do with the insurance, etc.

I hope this helps.  If you need more info, send me a private message. 

Good luck!!