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(deactivated member)
on 5/18/11 8:04 am - OH
on 5/18/11 8:04 am - OH
Topic: RE: Denial Received - Now What?
Ok I'm actually going through the steps to get approved right now, so I actually know what you are missing.
1. The insurance company didn't go through your medical records, they require that proof of a medically supervised diet be submitted with all the other paperwork to get approved.
2. There is no way to appeal that denial if it is in their outline for requirements.
So here it goes....My insurance also requires an attempted medically supervised diet for 6 CONSECUTIVE months to even be eligible for approval. You need to call your insurance company asap and ask them for a copy of their bariatric surgery guidelines (this really should have been your first step in the whole WLS process). In that outline, it will have everything the insurance company requires to get approved. Many insurers require the medically supervised diet. You need to find out how long they require it (most are 3-6 mo) and if there is outcome critera, such as a "failed attempt", or that you must lose 5% of body weight, etc. Then you will have to suck do it. I know it sucks!! I'm doing my 6 mo diet right now too. But unfortantly there isn't a thing you can do about it. Your surgeon's office may have a program that you can take, or you can just go through your PCP for it. Then you'll have to resubmit all your stuff after you complete that requirement.
So to answer your question...first contact your insurance, then your surgeon, then your PCP (if that's where you will do your diet). Trying to appeal this will be a waste of time UNLESS there was nothing written that it was required, but I think this was just a matter of not looking into the requirements closely enough. Good luck! I hope this helps.
1. The insurance company didn't go through your medical records, they require that proof of a medically supervised diet be submitted with all the other paperwork to get approved.
2. There is no way to appeal that denial if it is in their outline for requirements.
So here it goes....My insurance also requires an attempted medically supervised diet for 6 CONSECUTIVE months to even be eligible for approval. You need to call your insurance company asap and ask them for a copy of their bariatric surgery guidelines (this really should have been your first step in the whole WLS process). In that outline, it will have everything the insurance company requires to get approved. Many insurers require the medically supervised diet. You need to find out how long they require it (most are 3-6 mo) and if there is outcome critera, such as a "failed attempt", or that you must lose 5% of body weight, etc. Then you will have to suck do it. I know it sucks!! I'm doing my 6 mo diet right now too. But unfortantly there isn't a thing you can do about it. Your surgeon's office may have a program that you can take, or you can just go through your PCP for it. Then you'll have to resubmit all your stuff after you complete that requirement.
So to answer your question...first contact your insurance, then your surgeon, then your PCP (if that's where you will do your diet). Trying to appeal this will be a waste of time UNLESS there was nothing written that it was required, but I think this was just a matter of not looking into the requirements closely enough. Good luck! I hope this helps.
Topic: Ontario Health Insurance Plan
I was wondering if anyone has any experience with OHIP and also wondering how much time it usually takes from the initial family doctor consult with "starting the application process" to approval/denial from OHIP?
Thanks in advance, Kristin.
Thanks in advance, Kristin.
Topic: RE: Denial Received - Now What?
I would start by calling the Surgeons office and asking if they provide any asistance with denials. If they do, they will be able to tell you what you need from them
If they do not, ask them to provide you with your medical record and aslo call the insurance company ans ask them what specifically are they looking for and who should the infomation come from.
This is a start.
I am going through an appeal, for a different reason. If you have any additional questions, let me know I can try to help.
If they do not, ask them to provide you with your medical record and aslo call the insurance company ans ask them what specifically are they looking for and who should the infomation come from.
This is a start.
I am going through an appeal, for a different reason. If you have any additional questions, let me know I can try to help.
Topic: Denial Received - Now What?
Let me begin by saying my insurance is Wellmark Blue Cross Blue Shield of Iowa.
I had my information session at the University of Chicago on my birthday, April 26th, and my surgeon/psych/nut consult on April 27th. Everything went extremely well, and I was approved by Dr. Alverdy's team for surgery on April 29th with very few requirements (only needed a letter of medical clearance from my PCP, a copy of my latest hemoglobin A1c bloodwork, and participation in a mandatory PREP course). When Tracie from Dr. Alverdy's office called me yesterday to go over what paperwork was still needed, I found out she had already submitted the prior approval request on May 3rd. Needless to say, I was ecstatic, and also worried.
I received my denial letter in the mail yesterday, citing the following: "Based on the information available to us, this request does not meet medical necessity and is being denied as of May 3, 2011 based on the following: There is no documentation of physician monitored weight loss attempts within the two years prior to the procedure as required by medical policy."
I know there are many, many posts out there about being denied and asking how to proceed. I apologize in advance, because I am very frazzled right now. I'm not sure what my next step is. I don't know if I need to contact Dr. Alverdy's office, or if they will contact me, or if they will contact the insurance, or if I need to contact my PCP. I know I just received this Friday, but apparently there is a time limit for appeal. Any help and advice would be so appreciated right now.
The hard part for me, I guess, is that I don't really understand how they access your personal medical records from your PCP in the first place. There is a section on the denial letter that says: "Your physician has the right to speak with the Wellmark Medical Director regarding the requested service by calling the customer service number on the member's health card."
Sorry this is so long, but right now I don't know my next step, and I don't like to feel helpless. If anyone can help me with what I should/can be doing, I would be so happy and relieved. Thanks for listening.
I had my information session at the University of Chicago on my birthday, April 26th, and my surgeon/psych/nut consult on April 27th. Everything went extremely well, and I was approved by Dr. Alverdy's team for surgery on April 29th with very few requirements (only needed a letter of medical clearance from my PCP, a copy of my latest hemoglobin A1c bloodwork, and participation in a mandatory PREP course). When Tracie from Dr. Alverdy's office called me yesterday to go over what paperwork was still needed, I found out she had already submitted the prior approval request on May 3rd. Needless to say, I was ecstatic, and also worried.
I received my denial letter in the mail yesterday, citing the following: "Based on the information available to us, this request does not meet medical necessity and is being denied as of May 3, 2011 based on the following: There is no documentation of physician monitored weight loss attempts within the two years prior to the procedure as required by medical policy."
I know there are many, many posts out there about being denied and asking how to proceed. I apologize in advance, because I am very frazzled right now. I'm not sure what my next step is. I don't know if I need to contact Dr. Alverdy's office, or if they will contact me, or if they will contact the insurance, or if I need to contact my PCP. I know I just received this Friday, but apparently there is a time limit for appeal. Any help and advice would be so appreciated right now.
The hard part for me, I guess, is that I don't really understand how they access your personal medical records from your PCP in the first place. There is a section on the denial letter that says: "Your physician has the right to speak with the Wellmark Medical Director regarding the requested service by calling the customer service number on the member's health card."
Sorry this is so long, but right now I don't know my next step, and I don't like to feel helpless. If anyone can help me with what I should/can be doing, I would be so happy and relieved. Thanks for listening.
~Tara
HW: 318 / SW: 280 / GW: 150 / CW: 263
HW: 318 / SW: 280 / GW: 150 / CW: 263
Topic: RE: Blessing from Voc Rehab!
Heidi,
Congratulations on losing 74 lbs!! Great job. I have never heard of Voc Rehab, but I am happy your surgeon referred and it covered the cost of your surgery.
I had my surgery in March of 2009. My daughter had her surgery in May 2010 and my two sons had their surgery in Dec 2010! I am so thankful and grateful for having insurance that covered WLS as it would not have been an option for my family to self pay.
Again, congrats to you and keep up the good work!
Nan
Congratulations on losing 74 lbs!! Great job. I have never heard of Voc Rehab, but I am happy your surgeon referred and it covered the cost of your surgery.
I had my surgery in March of 2009. My daughter had her surgery in May 2010 and my two sons had their surgery in Dec 2010! I am so thankful and grateful for having insurance that covered WLS as it would not have been an option for my family to self pay.
Again, congrats to you and keep up the good work!
Nan
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
Topic: Blessing from Voc Rehab!
I just wanted to say how thankful I am to have had this surgery! I was a self pay for the lap band.. Had many problems lost a little weight but gained back more than I lost! I had to have the band removed due to many compilations and problems. I had no insurance or money! I felt like I was going to die from the weight and all my co morbidities.. Long story short my surgeon, referred me to Voc Rehab. and they paid for 100 percent of my surgery! It was a long process but So worth it! I was blessed in so many ways. I just wanted to share... I also what to thank everyone on the site for all of the support! I had my surgery on Dec 1st and have lost 74 pounds. I feel like a new person even though I have a long way to go!
Heidi
Heidi
Topic: Where should I have WLS
The difference in where you have your surgery
I have been doing a little information gathering in the past few days. I live in the state of Oregon and in the city of Eugene. I have discovered that they do NOT have anyone in my city to do WLS
.
I spoke with someone who was going to have to drive to a smaller city than we live in to have her sleeve WLS. Then I was shocked when she said they are doing it as DAY SURGERY and the doctor wants her to go stay in a hotel close to the hospital once they release her from Day Surgery—just in case something goes wrong she can return to the hospital quickly. The doctors have only asked her to say in a hotel for one (1) night then she can come back home—about 60 miles away from where she had the surgery. I was SHOCKED to hear that she is going to receive so little care from the doctor or hospital.
This just reaffirms why I went to Dr. Aceves in Mexicali, Mexico. I was cared for so differently. I spent part of one day getting all my tests done—which I am sure in the US they do the same thing. I had the opportunity to see the hospital and I also saw how often and how much they cleaned just being there for 3 hours for the tests. I was given paper work to fill out the night before surgery (which they must have you do in Oregon). I met with a doctor the night before (he comes to the Hotel you are staying in) the doctor who explained the surgery and how it is done went into great detail and asked if I had any questions and then spent more time answering my questions.
In the morning, I was assigned my very own nurse who was taking care of me—she got me ready for the surgery. That morning I saw the two surgeons, and the anesthesiologist, who again answered ALL my questions that I forgot to ask the night before. They explain exactly what they were going to do and what I would feel like when I woke up.
They would have NEVER sent me to a hotel to recover. I spent 4 days and nights in the complete fully equipped hospital seeing two doctors 3 times a day. I was given a battery of test before they would consider sending me home. On the 5th day, I was driven to the San Diego Airport and I flew home.
This is the kind of care you should EXPECT AND DEMAND if you are having this kind of surgery. You need to be doing your recovery in a HOSPITAL. So the next time someone makes the comment to me about why would I go outside of the US for this kind of surgery this is EXACTLY WHY. When you want the best you do your research and find the best. That is just what I did.
Now I can’t speak for other doctors in the US or other hospitals, only what I learned while doing a bit of research here in Eugene, OR If you are having WLS PLEASE ask the doctors, the hospital and those involved what their care is like, and what they will be providing you during your WLS.
YOU have the right to have the best care possible. You NEED to be your own advocate when it comes to your Health Care. NEVER SETTLE for anything less than the best when it comes to your health.
I have been doing a little information gathering in the past few days. I live in the state of Oregon and in the city of Eugene. I have discovered that they do NOT have anyone in my city to do WLS
. I spoke with someone who was going to have to drive to a smaller city than we live in to have her sleeve WLS. Then I was shocked when she said they are doing it as DAY SURGERY and the doctor wants her to go stay in a hotel close to the hospital once they release her from Day Surgery—just in case something goes wrong she can return to the hospital quickly. The doctors have only asked her to say in a hotel for one (1) night then she can come back home—about 60 miles away from where she had the surgery. I was SHOCKED to hear that she is going to receive so little care from the doctor or hospital.
This just reaffirms why I went to Dr. Aceves in Mexicali, Mexico. I was cared for so differently. I spent part of one day getting all my tests done—which I am sure in the US they do the same thing. I had the opportunity to see the hospital and I also saw how often and how much they cleaned just being there for 3 hours for the tests. I was given paper work to fill out the night before surgery (which they must have you do in Oregon). I met with a doctor the night before (he comes to the Hotel you are staying in) the doctor who explained the surgery and how it is done went into great detail and asked if I had any questions and then spent more time answering my questions.
In the morning, I was assigned my very own nurse who was taking care of me—she got me ready for the surgery. That morning I saw the two surgeons, and the anesthesiologist, who again answered ALL my questions that I forgot to ask the night before. They explain exactly what they were going to do and what I would feel like when I woke up.
They would have NEVER sent me to a hotel to recover. I spent 4 days and nights in the complete fully equipped hospital seeing two doctors 3 times a day. I was given a battery of test before they would consider sending me home. On the 5th day, I was driven to the San Diego Airport and I flew home.
This is the kind of care you should EXPECT AND DEMAND if you are having this kind of surgery. You need to be doing your recovery in a HOSPITAL. So the next time someone makes the comment to me about why would I go outside of the US for this kind of surgery this is EXACTLY WHY. When you want the best you do your research and find the best. That is just what I did.
Now I can’t speak for other doctors in the US or other hospitals, only what I learned while doing a bit of research here in Eugene, OR If you are having WLS PLEASE ask the doctors, the hospital and those involved what their care is like, and what they will be providing you during your WLS.
YOU have the right to have the best care possible. You NEED to be your own advocate when it comes to your Health Care. NEVER SETTLE for anything less than the best when it comes to your health.
Suzanne B
Eugene, OR
Dr. Aceves
10/21/2008
Start lbs 225
Now 120
Eugene, OR
Dr. Aceves
10/21/2008
Start lbs 225
Now 120
Topic: RE: Premera BCBS - Microsoft
LOL gonna answer my own post, just in case someone has the same insurance as I do and wonders.
The insurance papers were faxed Thursday May 5th, I got my approval today Wednesday May 11th.
The insurance papers were faxed Thursday May 5th, I got my approval today Wednesday May 11th.
Topic: what gets submitted first
ok so i have completed everything necessary to submit to insurance for approval but when i talked to my surgeons office they said they just sent my letters of medical necessity to my pcp and to wait a day or 2 then call my pcp. i thought letter of medical necessity went straight to insurance can anyone explain this process to me i was hoping to hear sumthing from insur soon but now it seems like its gonna take atleast a cpl weeks... oh btw i have healthnet hmo
tcb1979
on 5/10/11 3:44 am - SC
on 5/10/11 3:44 am - SC
Topic: RE: Should I appeal?
24 June. Due to work, my support person's schedule ,and a vacation to see my brand new nephew, that's the best time. I am so relieved it was approved now, because if not June, I would have had to wait until October. My work is crazy, so it's hard to get time off.
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