Insurance Help!!!

My insurance company has added 2 new clauses to approve WLS. One is a psyche eval...no problem. The other is DOCUMENTATION of attempted weight loss in conservative weight loss program for 12 months AND a loss of 3 BMI units. I have been on umpteen programs and have absolutely no documentation of any of it! How the heck do I do this... I am about ready to get a lawyer. These provisions were added on Jan 29th and I started the process on Jan 2nd. Help me!

Patricia- I have been fighting insurance for over a year now. The first thing they told me was that my BMI wasn't high enough (I was 39.5 and they would only cover people over 40), and that I needed a psyche eval and a consult with a nutritionist. I really wanted to just binge like mad and make up that little half point, but I figured that wouldn't be all they'd want. I started seeing my PCP for weigh-ins and blood work to monitor the "traditional medical methods" of dealing with my co-morbidities that the insurance company wanted. My meds just increased, as did my weight depending on what meds I was on, and my comorbidities expanded with my waist. I had to see two other specialists, one for an endoscopy and an endocronoligist for metabolic syndrome now that I'm diabetic. After I reached the 12 month mark, I sent a letter requesting a second level appeal. I sent color pictures of my esophogitus and hernia (courtesy of the endoscopy) my psych eval, letter from the nutritionist, and the entire year file from my PCP. I was able to speak with the review board via conference call and state my case - I emphasised other things than what was in my appeal letter, and they approved. Of course they approved two different weight loss surgerys, but not the one I was requesting, so I'm now moving on to an external review level appeal to fight for the Lap Band, but I did win on necessity. I know it seems impossible, but your best bet is to start NOW - then if you can get other suggestions about how to get around the thousand weight loss programs we have all done that we didn't keep the failed food diaries from, at least you are on the road. By the way, my insurance company wanted "Dr. supervised" weight loss programs, so they ruled out all the usual suspects - weigh****chers, jenny craig etc. They even went as far as to say that my stint with the pill pusher clinic where I went on phen fen for a year didn't count cause it was just a drug program and not a diet program... crazy I know, but I'm hanging in there, and DANG determined to get what I want. Keep fighting! Hopefully you'll get some advice from people that have actually gotten there, but I feel for you - welcome to the waiting room. -Dorothy

Thank you for your encouragement! It has been over a year now. The problem I am facing is that they change the requirements as it pleases them. I qualified last year but they only covered (are you ready?) the first 50% up to $4,000.00. What a joke. I work at a hospital. This hospital recruited the bariatric surgeon to locate here and perform bariatric surgery at our facility. Then they have the audacity to not cover us for the surgery. The bariatric surgeon threatened to locate elsewhere if our hospital did not cover its own employees for his surgery. So, this year it is a fully covered expense, but they decided (after Jan 1st) to add more hoops so hardly anyone would qualify. If I try to just continue to document everything that they want, they may very well just change the requirements again. I really can't wait that long anyway. I have arthritis so bad that I may not be able to continue to work. If I quit, they really win because then they will never have to pay for my surgery. If I go ahead and have it and pay for it myself (equity line of credit) and try to appeal and have them pay, I may lose and be so in debt that I lose my house (but gain my health). I feel so stuck between a rock and a hard place. I am trying to keep my chin up but I am losing hope fast. Meanwhile, I am on major pain meds, trying to diet (again) and failing (again) and contacting past physicians from where I used to live to get the documentation needed. Of course, everything is being done by mail and takes weeks. I originally expected to have this surgery in late Feb. Now I am hoping for summer! Like I said, I was already approved once last year! Grrrrr...... Oh well, anything worth having is worth waiting for. Patty

I used to work at a hospital and 12 years ago--that hospital. Isn't it interesting how short sighted they are. The medical profession drives me crazy about how it is OK to neglect their staff, but expect them to provide good care to everyone, work all the overtime they want, attend staff meetings, work on committees, etc, etc, etc. I don't work at a hospital anymore, because I got so sick of the abuse. You hang in there and keep fighting. You deserve this surgery, and don't let them win. Good luck! Eileen