What am I going to do????
Hi everyone, this is my first post and I'm sorry to say it's not a happy one. First I want to give you a little background about me. I am a 28 year old mother of two, I recently graduated from Nursing school. I just passed my nursing exam and I am currently an RN looking for a job and hoping to have gastric bypass so I can be healthy and keep up with physical nature of working as a nurse..12 hours shifts on your feet all day. I have a BMI of 49.7 I went for my psych eval about a month ago and it was the most uncomfortable experience of my life. I answered all his questions honestly...Like "Have you ever purged or refrained from eating at any point in your life?" My answer was, yes, once or twice in middle school after being picked on by other kids I try to not eat anything for a week or eat crap and purge. But, seriously, it was once or twice and I was young and immature and I would never do anything like that now, which I explained to him. "Do you ever have mood swings around your spouse? Do you love him one day and hate him the next?" ummmm "yes!" isnt that most normal couples????? "Are you depressed or have ever been treated for depression?" ....."yes but my PCP closed her practice and I had to wean myself off proza****il I could find a new PCP" I currently have medicaid and I'm one a "plan" under medicaid.....I meet all the criteria for gastric bypass surgery and have done all the tests and nutrition visits....a year long process!!!!! I WAS DENIED BY MY MEDICAID PLAN!!!!!!! and this is their reason
" After review Your request for authorization for Lap. Gastric Bypass was determined that it does not meet criteria required for bariatric surgery and will therefore be denied. Clinical information available at the time of review includes a request bariatric surgery for a member found, on pshychiatric evaluation, to show evidence of borderline personality, untreated anxiety disorder, and untreated/treatment resistant, long standing depression. There is a history of an eating disorder and self injury. Based on the presence of multiple psychiatric contrindications to bariatric surgery, we are unable to approve the request"
My surgeons office was floored and said they have never encountered anything like this before. We are appealing and I wrote a letter on my behalf to explain that I am now being treated for the depression and anxiety. My question is......What if they deny my appeal? What can I do? In a perfect world I would to get a second opinion/ or another psych eval done by someone different...can I do that??? Has anyone gone through this??? I am trying to stay positve, but I was made to believe this was going to be a sure thing I had all my ducks in a row and psychiatrist I saw actually cleared me for the surgery but my insurance found a loop hole. My heart is breaking I am 28 and I weigh 336lbs I am so ready for this and I have researched my butt off on how to live after surgery. ANY HELP OR SUPPORT WOULD E APPRECIATED.
" After review Your request for authorization for Lap. Gastric Bypass was determined that it does not meet criteria required for bariatric surgery and will therefore be denied. Clinical information available at the time of review includes a request bariatric surgery for a member found, on pshychiatric evaluation, to show evidence of borderline personality, untreated anxiety disorder, and untreated/treatment resistant, long standing depression. There is a history of an eating disorder and self injury. Based on the presence of multiple psychiatric contrindications to bariatric surgery, we are unable to approve the request"
My surgeons office was floored and said they have never encountered anything like this before. We are appealing and I wrote a letter on my behalf to explain that I am now being treated for the depression and anxiety. My question is......What if they deny my appeal? What can I do? In a perfect world I would to get a second opinion/ or another psych eval done by someone different...can I do that??? Has anyone gone through this??? I am trying to stay positve, but I was made to believe this was going to be a sure thing I had all my ducks in a row and psychiatrist I saw actually cleared me for the surgery but my insurance found a loop hole. My heart is breaking I am 28 and I weigh 336lbs I am so ready for this and I have researched my butt off on how to live after surgery. ANY HELP OR SUPPORT WOULD E APPRECIATED.
Sorry to hear about your denial. You say the psychiatrist actually cleared you? If that is the case, and I were in your position, I would have that psychiatrist resubmit the report and write a letter explaining reiterating that you were cleared and that he/she recommends you have the surgery. If that won't happen, I would get a letter from whoever is currently treating you for your depression/anxiety AND get at least two more psych reports to support you for the surgery. That info will come in handy when your wl surgeon resubmits or appeals. Good luck!
HW 304, SW 291, GW 160, CW 140 H-5'9.5"
if your psych cleared you then he honestly believes your fine... now anwer me this the person that made the decision to deny your claim.. is she/he a psych and if not what qualifies her to make such a decison? thats your appeal.. if an expert had already cleared you then why should and insurance rep denied you....they are not psych prefesionals ...go to different psych and get more letters that state that you are no longer depressed and then they will have no reason to deny you.. good luck..sending you lots of prayers...
Yes, of course you can get a second opinion. And you should. As well as writing a letter to the insurance company.
Also, I would reques a copy of your chart from the guy that evaluated you. See what's in it. For instance, if it says you binged and purged once in middle school in your chart, but the document he sent to the insurance company just says history of eating disorder, you can send his own notes to the insurance company with your appeal.
Also, I would reques a copy of your chart from the guy that evaluated you. See what's in it. For instance, if it says you binged and purged once in middle school in your chart, but the document he sent to the insurance company just says history of eating disorder, you can send his own notes to the insurance company with your appeal.
Kelly
Please note: I AM NOT A DOCTOR. If you want medical advice, talk to your doctor. Whatever I post, there is probably some surgeon or other health care provider somewhere that disagrees with me. If you want to know what your surgeon thinks, then ask him or her. Check out my blog.
Thank you everyone for your advice! I am going to fight this tooth and nail. I was just so discouraged, but luckily my surgeon's office said that a totally different person would be looking over my appeal. I just thought that during my eval I would be brutally honest about how my weight has challenged my life and made me depressed. I really thought that would work in my favor. My appeal was sent in this week so hopefully I will have some good news! Thanks everyone xoxoxo
For a successful appeal you need to show them evidence that contraindicates the reason for their denial.
A letter from whomever treats/treated you for depression will go a long way. Is this 'anxiety disorder' a new diagnosis that the person that did your psych eval made? If that's the case then a second opinion from another psych might be helpful to you. A letter from your surgeon, and PCP is also helpful, plus if the psych has cleared you then they should also give you a letter of support.
A letter from whomever treats/treated you for depression will go a long way. Is this 'anxiety disorder' a new diagnosis that the person that did your psych eval made? If that's the case then a second opinion from another psych might be helpful to you. A letter from your surgeon, and PCP is also helpful, plus if the psych has cleared you then they should also give you a letter of support.
FleurDeLis
on 12/10/11 4:16 am
on 12/10/11 4:16 am
In my state Medicaid pays so little that it doesn't even cover the cost of disposables in the OR. Iowa Medicaid recently tried to drop the coverage entirely. It is routine for insurance companies to deny coverage the first time around. They know a lot of people will give up at that point or switch insurance companies, saving them money. So it may not be you.
I'm betting whoever did the review did it so fast they were just looking for the words they could use to routinely deny coverage. Prpbably never even saw it was as a child and a one-time thing from bullying.
Your own psychiatrist would be the better person to evaluate your condition since that doctor has extensive experience with you. They could confirm or deny anything in that other report with more authority.
A new person will be doing the appeal, but you need this person to have more information or the result can be the same. Most places will take the word of an attending psychiatrist over a stranger psychologist. Make sure they get it.
Do get a second opinion. My first psychologist was in a building without an elevator. She would not change location and I had to go four times. I'm super morbidly obese with a history of heart disease. The second psychologist voluntarily offered to give me the contact information for our state psychology licensing board when she heard that.
Talk it over with your psychiatrist on what to say and how to say it clearly if you need a second opinion from a psychologist. See if you have to see a second psychologist at all or if your own doctor's recommendations will be acceptable.
Once you are employed, you should be off Medicaid. At that time hopefully your employer will cover WLS. Try to get employed by a hospital that does WLS to increase the odds it is covered. You may have to wait until a vaction to do it, but any physician-supervised visits that you require that you have already made should still count if they are not too old.
I'm betting whoever did the review did it so fast they were just looking for the words they could use to routinely deny coverage. Prpbably never even saw it was as a child and a one-time thing from bullying.
Your own psychiatrist would be the better person to evaluate your condition since that doctor has extensive experience with you. They could confirm or deny anything in that other report with more authority.
A new person will be doing the appeal, but you need this person to have more information or the result can be the same. Most places will take the word of an attending psychiatrist over a stranger psychologist. Make sure they get it.
Do get a second opinion. My first psychologist was in a building without an elevator. She would not change location and I had to go four times. I'm super morbidly obese with a history of heart disease. The second psychologist voluntarily offered to give me the contact information for our state psychology licensing board when she heard that.
Talk it over with your psychiatrist on what to say and how to say it clearly if you need a second opinion from a psychologist. See if you have to see a second psychologist at all or if your own doctor's recommendations will be acceptable.
Once you are employed, you should be off Medicaid. At that time hopefully your employer will cover WLS. Try to get employed by a hospital that does WLS to increase the odds it is covered. You may have to wait until a vaction to do it, but any physician-supervised visits that you require that you have already made should still count if they are not too old.
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