lw152

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I had great results with the VSG but encountered dificulties about 2 years years out. At first the weight gain was slow then even after correcting some diet issues it continued. I think this was in part due to a medication after the medication was changed I started to lose again. I ended up with large hiatal hernia, severe GERDs and an hourglass shaped sleeve. The spasms and reflux has been so bad that I have had difficulty eating and sleep upright most nights. After two GI's and Two surgery consults everyone agrees the best solution is to convert to gastric bypass. My surgery date is April 5th, 2017.  I've already lost most of the weight again, but continue with reflux and difficulty eating enough. I will be glad to have the surgical correction completed, but feel a little nervous.

After 2 years of denials and 3 canceled surgery dates I was approved and sleeved on April 4th. Whoo hoooo! 
The surgery was a little rougher than I thought it would be. The first two days I had a lot of nausea. Today I am 3 days post op and doing well. Like everyone says sip, sip, walk, walk. Each day gets a little better. The day of surgery of surgery I weighed 218.7 today I am already down to 207!

Someone from Meritain called me in the middle of the last week and said that they were speaking with my HR department and would call me back by Friday. I had again asked for the summary plan criteria states a time limit. It doesn't exsist so the lady sounded hopeful and said they were discussing it with my HR
When Friday came there was no call and at 4:30 when I called them everyone searched and said there were not any notes in the computer and that they always put notes. That I had been denied and that is all.
I can't believe the games that these insurance companies are allowed to do. Especially the self insured ones. I should have immediatly asked for call back number and name but I got so hopeful that i didn't even think about it.
Obesity law emailed me and said they were looking over my information to see if they could help.

Well Meritain just denied sending authorization again, so this is the 2nd time my surgery has been canceled. They state that I do not meet plan criteria because I lost some weight over 2 years ago and went under 35 BMI. They do not have in the plan criteria and canot produce any document thats states you must be 35 BMI for 3 consecutive years. They do not have posted in their plan at all a time limit. Other plans have it available for their clients.
What is worse I have taken out another policy and they sat on it until the last minute, my surgery was scheduled Tuesday 26th. They just called to inform me at 4:30 PM. I do not even have time to submit to the other company they left me with one business day.
Today I had to rush my cardiologist to do last minute add on clearance because the anthestiologist requested. Yesterday I also did tests. I had called again and asked for expedited decision last Monday because I knew deep down they were going to pull this.
Frustrated

Maybe I am wrong but I feel frustrated that I don't have an autherization and I am starting a liquid diet again today. Last Oct I was 6 1/2 days into a liquid diet when they called and told me my surgery was canceled. I called the insurance company again and they said they would put an urgent request. When I called last week they said that my surgeon's office just submitted the same information package that I got denied with before that it did not include any new information.
When I called the surgeons office concerned she said I wasn't supposed to be calling. That she wanted to submit it like it was new.(They have computers)
When I called today I kept apoligizing and the insurance company said no you have a right to call you can call every day if you want, that is what we are here for.
I am begining to wonder if they are just jerking me around at the surgeon's office. When I ask about submitting to my secondary she just told me no your primary has to pay. I already spoke to my seconday Blue Cross Blue Sheild and they said all I need is a denial letter from primary.
I wonder now if there is some other reason. They submitted on Mar 31th.

If this doesn't go through this time I am finding a different surgeon.

I guess I will just leave this avatar because for some reason it is stuck to the picture I tried to upload...lol
I keep deleting and uploading the picture and the cartoon just keeps coming back...hehe oh well I will fix another day.

Well they went ahead and gave me a schedule again and faxed my primary (changed from last time) a request for surgery clearance.
I am scheduled for April 26th surgery. Start liquid diet 4/19/2011. I don't want to get excited to much again.
Surely with two different policies one will approve.
Before I start the liquid diet again I am calling. Not that I couldn't benefit from a week of liquids.
I am going to have pre-op bloodwork and chest x-ray Monday.

Yesterday I spoke to the surgeons office and they resubmitted my request for approval again. I felt excited but didn't want to get my hopes up too much. 

I went to see my surgeon again and they are going to resubmit!
I might be able to do as soon as 10 days from now. She said she might possibly know something by Monday. Yea!!!!!
I am not getting too excited because it through me for a loop last time when I got denied.

I started my journey last May 5/2010 when I made my first appointment. After 5 months of appointments and tests I had a surgery date of Oct 12, 2010. I started the liquid diet and 6 1/2 days into it my surgeon's office called and said my insurance did not send authorization. All along the way I questioned are you sure I qualify and was told yes, you have a BMI of 36 as long as you do the program. (I have multiple co-morbidity's) I also had great difficulties with my primary he wrote the surgery clearance did the tests and I had to fight to get him to write my letter of medical need at the very end. I found out our plan  penalizes doctors who recommend too many surgeries.
My insurance does not specifically state a time line that you should be above 35 BMI for 3 consecutive years prior to surgery, but that is the excuse they used for denial. They stated on telephone that a group reviewed my request and it is standard practice that one must be obese for 3years. I appealed and they stayed with the same statement. It says I now qualify but would have needed to be > than 35 for 3 year to met plan criteria (which does not exist). I reported them to US department of labor and ERISA just to get a denial letter. They were so arrogant they just kept saying you don't met plan criteria and we don't even have to respond. It took over two months 12/2010 just to get appeal letter.
  I have a 24 year history of weight issues but have lost weight as much as 80lbs and eventually regained.
Today I have added a second insurance and have another appointment 3/10/2011 with the surgeon.
Today my BMI is 40.2
The new plan is Blue cross of Florida which does say one needs to have a 2 year history.
I still have my primary which is administered by Meritain which has no time limit in plan criteria. I believe they should pay!!!!!!!
Frustrated.......