Got a letter from insurance today/ dying here.A A

I was out running errands today, but this morning I called Vicki at Barix (ins. coordin) and asked for an update.  She called at 4:00 pm and said she'd rec'd a letter from my insurance and they need a favorable nutritional evaluation for surgery and a post op plan.  She sounded upbeat & positive that we'd just submit these things. I got home and there was a copy of the letter she'd rec'd obviously.  Here is what it said.............. Dear Dr. Poplawski, Your request for prior approval to perform a  Roux-en-Y gastrojejunostomy Lap-GE-Long (CPT 43645) on myself has been received inour office.  The submitted medical information including the psych. eval, letter from pcp, and office notes have been reviewed to determine medical necessity for coverage under the provisions of said company plan. Physician review recommendation is that at this time the  proposed gastric bypass procedure is not medically necessary for this patient.  There is not evidence of a favorable nutritional evaluation for surgery and no documented evidence ov the patient's ability to comply with the necessary lifestyle changes that are required post-operatively.  The said plan limits coverage for Morbid Obesity to only " medically necessary charges".  Please see manual pg. so in so for coverage.  Coverage is not available for the proposed procedure at this time. When a claimant rec"s           I have 180 days to dispute or appeal this. What does this mean??????????????????? Sounds like a denial to me.  If I give them what they say they denied me for are they more apt to grant approval??  Any advice on this would be most appreciated. ~Hugs, Steffanie

It sounds to me like you just need to get with a nutritionist for the evaluation and to make a post op plan in writing.  The insurance girls at Barix know what to do. Don't worry, it sounds like approval is just around the corner. The insurance just wants to make sure you jump through all their many hoops before paying, probably hoping that some will just give up and save them the money.  But you will get the documentation you need and hopefully be scheduled before summer is over:)  Keep a positive attitude.  Keep me updated!

Yes I agree I too think that you just need to call Mary at Barix and talk with her....If so I had to do that also and just talk about how things will be after surgery.....that was easy....Hang in there and let us know how you are doing

I know that i had to have a long medical history of supervised weight loss.  Most insurances require 6 months to 1 year.  I had all the dates and diets back to when I was 13 so that wasn't a problem.  I wonder if this is what they want.

Steffanie,
I just want to say, don't give up!  I noticed that they stated "Coverage is not available for the proposed procedure at this time."  So, they haven't closed the door yet.  Just work with the clinic, they are very good at what they do! Good Luck

Wow I'm amazed at how many people have read my post!!  It's a pretty interesting one I think.  Thank you so much for the support!!  I talked with Mary (nut.eval person) via phone and she was going to get the info we discussed on the phone today out to them right away!  Like I said Vicki has the post op plan it appears they want!  I'm never going to give up on this, NEVER!!!!  I met all of the criteria they asked for and yes, to those wondering I most certainly did do the 6 mos. supervised diet with my pcp.  Not to mention a million others in my life.  I went through the criteria letter which you can see on my profile, item by item to make sure I had everything they needed before I even submitted.  Neither of these two items were mentioned.  I did call ins. today and they said just submit those, and it's not even considered an appeal??????  What???????  I wrote her name down.  I'm keeping good notes now, and if I need a lawyer I'll get me one!  They will wish they would've just said yes if they don't!  I'm not one to sit quietly by and let things just blow on by.  I'll give Barix a chance to get this approved first though!  Prayers and good thoughts are what I need right now.  I'm thinking a good ice cold brewski would do nice as well! Thanks my pals! ~Hugs, Steffanie

It just means if you don't get the papers they need to them then it will be denied......but you aren't denied yet.   Linda

You are so on top of this!  It sounds like you are well on your way and they know what to do at Barix.  It will happen, keep the faith!  Take care!