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BurberryBenz
on 9/20/10 12:31 pm, edited 9/20/10 1:28 pm
Topic: Walmart BCBS WLS Exclusion / Other Options?

Hello, just a little background info on me first.

I am 23, female. 5'9", 360lbs. Size 22/24. BMI of 53.X. 

I have gained 180lbs in the past 8 years. I've had thyroid testing twice, that's not the problem. 

I tried gym/home dieting from 2005-2006. I've tried medically assisted weight loss 3 times with one facility between 2006-2007. I tried Medi-Fast in 2007. I tried Metabolic Research Center for 4 months in 2008. I talked to a psychologist re: emotional eating for 6 months in 2008. I tried hypnosis in 2009. I then tried medically-assisted weight loss in 2009 for a few months again. I also tried the HCG fad in 2010. I then got a dietitian in 2010. I've lost, at a most, 15lbs, but put it all back on and then some. I've been on prescription drugs for anxiety/depression due to this personal failure since 2005.

I don't have diabetes, high blood pressure, high cholesterol. I do have depression, anxiety, skin problems, and underwent a sleep study and was diagnosed with sleep apnea this year. I sleep with a CPAP machine. I do it faithfully as I know without it, I will fall asleep throughout the day. But because of my extremely sensitive skin, I have switched facial masks 3 times, but I am getting horrible skin reactions on my face from it. I have put fabric barriers over the plastic pieces to stop irritating my skin, but my skin is still irritated and I've had to purchase very expensive creams for my skin to relieve the irritations as they are the only things that work.

My gynecologist referred me to a bariatric surgeon two weeks ago. I went to a seminar that outlines the obesity information, types of surgeries performed, etc. 

It all sounds great. I'd like to proceed with a RNY Gastric Bypass. However, my insurance is with BCBS Arkansas Advantage and it specifically excludes any type of weight loss treatment, surgery, medication, etc. for obesity and morbid obesity.

My insurance company is so ridiculous that when I went to the doctor for my depression, when the doctor had put one of my diagnosis as "obesity" (which he always does?); the insurance company denied the bill. Citing they do not cover charges relating to obesity. I wrote a letter back informing them that 33% of people in my state are obese and if every one of their bills was denied simply for the fact they were overweight, then they should be informed of such when they were accepted as a member and their money should be refunded. They paid the bill.

So, therein lies the problem.

1. My insurance doesn't cover the surgery.

2. I applied for a loan through CareCredit to self-pay for the SX ($18,500 inclusive of surgeon/anes/asst. surgeon/pathology/OP facility). I was denied. (Probably because I have two car loans.)

3. I don't have a house to refinance to get extra money?

4. What can I do now? What are my options?

 

Thanks.  :)

mrsconrad
on 9/20/10 4:19 am - Steger, IL
Topic: Waiting...appeal vs pre-cert... Aetna
So now, I guess Aetna is saying that my case is not a pre-cert but an appeal, because they ruled against me back in March.  Very complicated...  So they are treating it as an appeal, which means it has to go in front of some type of review board...

I am so confused...

Maria
        
fordrachel
on 9/20/10 12:09 am - memphis, TN
Topic: RE: NAN2008!!! YOUR LETTER GOT ME APPROVED!! BY CIGNA!
Hey ladies, I am off my way on my JOURNEY.  Initially I was declined because my BMI was under 40.... But I have SLEEP APNEA and GERD. But, because my BMI was under 40 CIGNA still denied me.  I gained... get this......  7+ pounds (under 10 lbs), and that put my BMI at 40.4 (I am only 5 feet tall). I went in to be re-weighed, and took this letter to my PCP, and the PCP signed the letter, and the surgeon faxed it over on Monday--August 30th, and I was approved on Friday-- Sept. 3, 2010!   

I HOPE IT WORKS FOR YOU, THE WAY IT HAS WORKED FOR ME!!!  

              
Hello... My name is Rachel, I am 5 feet tall.... sign in BMI 40.4...  pleased to meet you!!!
Starting BMI between 35 and 40ish? 
Join us on the Lightweights Board!
moving-on
on 9/19/10 2:25 am - Rimrock, AZ
Topic: RE: NAN2008!!! YOUR LETTER GOT ME APPROVED!! BY CIGNA!
Wow that is so exciting.  I am going to try this letter as well.  I got approved on Aug 31 and started the whole process of testing and even was on the liquid diet for a week and boom get denied 2 weeks later.  I have been just devastated.  I wouldnt have been so depressed or upset if I got the declination first, I was prepared for a battle with the insurance company.  I have been calling anybody and everybody and it looks like the long and short is they dont like that I started taking Zoloft in April of this year.  Insurance company said they didnt like that i was being treated for Chronic depression..... What!!! since April.  Gees, i am a single mom of two teenage boys (both of which are ADHD/ODD) and things have just become overwhelming.  Between my declining health and raising kids I get very high anxiety and felt i needed some help for now... I know the insurance company is just looking for a way out, but I am looking for a way in and with this letter I hope to succeed just as you did.  (sorry for the long post :)  I am just frustrated and hope like you i will get an approval.
Moving on to better health        
Amanda H.
on 9/17/10 2:18 am - Cooperstown, NY
Topic: Not fat enough now....
My insurance just denied me during the "peer-to-peer" review with my surgeon because, get this, now I'm not fat enough. 

In January of this year, I called to determine whether it was a covered benefit, and they said that my procedure (sleeve gastrectomy) was.  They cover this procedure if your BMI is over 40, OR if it's 35-40 with two comorbidities.  My BMI was 42 when I entered the bariatric program I eventually chose.  However, the 10% pre-operative weight loss put me at a 38.2 with no comorbidities.  

So I was declined.  Twice.  Now, I have to go through an internal appeal and an external (state insurance board) appeal process.  This is SO unfair!!!  I've become SO committed to this as a lifestyle choice that when my surgeon nudge-nudge, wink-wink hinted that he wouldn't hold me back from surgery if I regained the weight to get over a 40 BMI, the idea (if not the compassionate, sympathetic way it was presented) was distasteful to and angered me.

Anyone have any words of wisdom about fighting insurance companies?
M. DeVenney
on 9/16/10 11:03 am - Phoenxiville, PA
Topic: RE: BCBS Georgia
I am sorry you are having such issues. I worked in the medical insurance industry for years. Your parent's employer actually chooses the coverage. The insurance company only administers that coverage. So, it is possible that someone else, with the same insurance company (BCBS Georgia) who works for another employer/company is covered for bariatric surgery while you are not.

I know this is all crazy, but switching insurances won't help if the employer has rejected Bariatric surgery from the plan (because of cost) another insurance company with the same employer will most likely exclude the same benefit.

If one of your parents is employed with another company, it may be worth trying to see if that insurance company has Bariatric surgery covered. If it does, you can try switching to that parent;s plan. If not.....you need to get a job with insurance coverage yourself or start saving!! I hope this information helps. Good luck to you!
ambo424
on 9/16/10 12:04 am - berkeley heights, NJ
Topic: RE: looking for cigna approval

i haven't been approved yet (although everything's being sent to cigna this week!), but my cigna plan required me to do the 6 month diet, a nutrition apt, and a aquire psychiatric approval.  my surgeon also made me have an edg.  my only reccomendation is to get all of the other appointments overwith before the end of your 6 month diet, so that way when you're done with the 6 months, your PCP can write a letter and send it off. good luck :)

kjm92002
on 9/15/10 4:45 am - gastonia, NC
Topic: RE: Need help and/or advice
Thanks for the reply, I've recently began to look into finding another dr, I don't htink that financing would be to good of an option for me, so hopefully everything will work out for the best, thanks for the good luck wishes

Dorian
BeautyisherGODgiven
name

on 9/14/10 6:45 am
Topic: RE: looking for cigna approval
my cigna plan also required 6 months. It started 8/31.. yeah, we are in it for the long haul
Follow my progress: www.youtube.com/user/livictori                           
    
BeautyisherGODgiven
name

on 9/14/10 6:42 am
Topic: RE: NAN2008!!! YOUR LETTER GOT ME APPROVED!! BY CIGNA!
if is not to forward of me; may I ask why you were denied?
Follow my progress: www.youtube.com/user/livictori                           
    
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