Denied even though I have met all the requirements...what to do??

Hi everyone, First and foremost, thank you for taking the time to read my post. I've been working  very hard to try and obtain WLS since 2006 and am just about ready to give up. In September of 2006, I visited my then PCP about my weight (BMI of 50) and he prescribed to me weight loss medication and we discussed my joining a gym and dieting. I continued to visit my doctor over the next few months to see my progress but I only lost 4 pounds. Finally in February 2007, my PCP and I decided WLS would be a good thing for me since I am a perfect candidate. I submitted all my documentation or past weight loss attemps, timelines, gym membership copies, prescription copies...everything. Unfortunately, literraly the week my docs were sent to the insurance for an authorization to see a surgeon, I was laid off from my job. So I lost my coverage. That was the end of that because I could not afford to keep the coverage via Cobra. Fast forward,as of December 2007 I became eligible for state MediCal health care. The managed health care program I chose was HealthNet (through Medical). That very month, I started seeing a new PCP to get the ball rolling on the surgery. Unfortunately, my PCP isn't very helpful but he agreed to submitt all the documentation for the authorization as well as all my previous health records from the last PCP. Well, long story short, my request for authorization was denied. Mind you , this request for JUST for the surgeon consult, not even for the procedure. I then got on the phone with the medical group (Pacific IPA) and they told me that my doctor had not submitted any documents that would deem the procedure medically necessary adn that they had sent him a request for additional info twice - to which he never responded. So, I gathered all my documents adn evidence and submitted everything to the medical group myself (35 pages worth!) and they had a meeting about my case yesterday to see if it could then be approved with the new info. Unfortunately it was denied, again. Here is my problem: I dont' know why they denied me. According to the denial letter I do not meet the requirements which say (verbatim): "This request is denied because your Health Plan has established criteria for the surgical treatment of morbid obesity. Surgical treatment of morbid obesity will be covered only when specific criteria are met as follows: BMI over 40, failure to lose weight significantly or regaining of weight despite compliance with a multidisciplinary nonsurgical program including low or very low-calorie diet, supervised exercise, behavior modification and support, with pssible medication; no specifically correctable cause for obesity (eg, an endocrine disorder). You do not meet the criteria of previous weight loss attempts with medical supervision to qualify for gastric bypass surgery for management of your condition." But I DO meet those requirements, I do have a BMI over 40, I have had a doctor supervised weight loss attempt and I have been screened, twice, in the last year with blood work to determine if I have a condition (thyroid disorder, etc) that might be causing my weight gain. I also submitted copies of my gym membership/contract which initiated the same month I started the prescribed weight loss medication - so wouldn't that could for supervised exercise? I know this is a super long post you guys, and I'm so sorry but I don't know where else to turn. How can I file an appeal if I don't even know WHY they denied my request?? Or how can I try to meet the requirements (that they say I dont meet) if I don't know exactly what it is they want me to do ...I've done everything I think I can. They did approve me for a dietician consultation. Aside from that - no clue what to do... Can anyone give me some suggestions and or information as to what I can do?? thank you, thank you, thank you....

The only thing I can suggest is that they might want proof that you've tried to be part of an organized official DIET program, such as Weigh****chers. I know my insurance seems to want that too and my PCP saying we've discussed my diet repeatedly is not enough. So maybe it's the same case with you. Perhaps thats why they approved of meeting with a dietician? I'm also a little confused why you have to be approved for a surgeon consult. Can't anyone just go? I just attended a seminar and made an appointment. Sorry I can't be of any more help, but hopefully someone who's been on this website longer might offer more useful info, Good luck! Nia

You probably need a 6 month Dr. supervised weight loss program with weigh ins, exercise consultatons, dietician/food program.  They want 6 consecutive months of weigh in-don't skip a month or they will deny it.  5 years of proof of morbid obesity.  List of all weight loss programs  and medications you have participated in.  Your Dr. records must show all the elements above every month. Do you have Diabetes, sleep apnea, degenertive disk disease, high cholesterol, arthritis?  They are looking for the co-morbidities.  Thyroid is probably not considered a co-morbidity, but you should include everything that you can.   If you don't have the above, you might want to start the monthly appointments and when you hit your 6 months, then re-submit.  Go to the dietician and keep all the documentation and appointment receipts, food journals, etc. . 

First of all - Hang in there! I think it is true that what they are requiring is the "6 month medically supervised weight loss program."   You should get a copy of your insurance plan description and see what it says. If you can, contact someone at the insurance plan who will take the time to confirm for you, what the specific reason for denial is.  I was denied for 3 years! One of the times, it was because of a newly added 6 month medically supervised requirement.  It is tricky - If you miss any of the 6 months of appointments by a day, the 6 month count starts over.  Certain specific things must be documented carefully by a doctor who knows exactly what they are looking for.  I went to a doctor associated with my surgeon's office, and I have to say - it was money well-spent. Not only did I complete the 6 months with everything the plan wanted, I still carry with me much of what I learned during those 6 months.  Weigh****chers is not what they want, nor is a gym membership.  My friend went to her PCP, who was very, very careful to do things exactly as required by my friend's health plan, and tin this case, the health plan was very helpful.  But my friend was lucky - although my PCP supported my quest to have surgery, he really didn't know what was needed, and my health plan wasn't tookeen on making it any easier.  So you should find a doctor who knows - maybe through your surgeon's practice? - and I bet it will make the difference.   Also make sure you have a sleep study for sleep apnea. A pulmonologist  can refer you for one.  After 3 years of denials, I submitted again with a sleep apnea diagnosis, and was accepted within one week! Good Luck! Let us know how it goes... Maxine

They're wrong, appeal it, and if you lose, then you go right to the state of cal insurance department and get them to overturn it on external review.