Denial, Appeal & Approval - Lots of words ending in "L"

Jul 11, 2009

It's been a rollercoaster. I don't know why I'm so surprised -- I thought for some reason I'd go through this process without a single hitch, like some insurance God was looking over me. I would just skate through from start to finish with very little speedbumps. I was very wrong.

After meeting my goal (see previous blog), I faxed my weight to my case manager at UMP and let them know I chose Virginia Mason. I then received a phone call from him saying they never received my medical records from Group Health Cooperative, would I get them? I said sure and sent GHC a request for my sleep apnea test result (I had to have one of several listed medical conditions in addition to obesity to be approved). I received my test and faxed it to UMP.

A week or two passed and I hadn't heard anything or received the referral to Virginia Mason. I called my case manager and left a message. The next day, I received a call from him. He said he and the department's doctor reviewed the test results twice and it showed I did not have sleep apnea. He explained without the records, I shouldn't have been let into the program so at this time, I would be denied.

I got upset, thinking I'd been using my CPAP machine for almost 10 months and have felt a significant improvement; how can this be? Luckily, he explained how I can appeal and what to include in my appeal. Unfortunately, the records had to have been created before my acceptance into the program, so prior to January 2009.

I set forth, requesting all my GHC records. They showed the sleep doctor did diagnose me with sleep apnea AND high cholesterol, both conditions which are acceptable for the program. I put my appeal together. mailed it off to UMP and held my breath.

I was able to exhale Friday July 10th when the program director with UMP called me and said my appeal was accepted. I was back into the program where I left off - waiting for a referral. I feel I'm finally back on track with my life.

Prior to July 10th, I had been going downhill. I injured my knee and haven't been able to exercise much, if not at all. Slight wrong movements cause a shooting pain and I'm afraid to push anything. I've had an MRI and will be meeting with the orthopedic doctor on the 17th. Hopefully it's good news.

I'm more inspired now than ever to do this, especially with my father's health going downhill. He's diabetic which has resulted in a kidney transplant, amputation on one leg, and countless surgeries. Now he's getting his other leg amputated. It's been hard to handle, but it's just inspired me to be a healthier person.

So wish me luck! Looks like I got the insurance gods back on my side :)

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