Need asssistance

This will be the 3rd time i post asking for someone letter writing ablility to try and get intervention done on my WLS. I have all the medical problems needs however i am just 70# over weight not 100# but i recently had a heart attack, chlestrol and trycricerides are high taking tons of meds. Both Primary and Heart doctor said to get the weight off and i could go off 3/4 of the meds. So i am looking for someone who does good letter writing that can help me compose a letter. Please let me know ASAP seeing primary on 9/28/05 mystic

Mystic- Have you posted this on the main board? Have you looked at any of the sample letters. I would think you probably need someone with a medical or insurance background. I looked for your profile but there was nothing there. Is there an exclusion? Does your insurance require a high BMI or is it by weight? Do you know if anyone has ever successfully gotten past the restriction? Which insurance do you have? Will your PCP recommend you for the surgery? How tall are you? Have you applied and been denied? Has or will your cardiologist write a letter? I did not see your other posts and we need a little to go on. Red

Thanks Red I am new here...not sure what all I need. My primary and cardic would approve and my primary has documentation on every pill, diet regular ones and ones through the hospital here and recent heart problems. He told me to compose a letter and then he would do one to submit to the insurance company.My BMI is 32 i think. Not sure I have Humano HMO here in Florida. 5 6 and I weigh 197#. I have not applied yet but once I have my letter sumbitted to my primary he would take it from there. Where do I find the letters that you are referring to.

MYstic- Do you know what your policy states about WLS? Not all Humana policies are the same. A lot depends on whether it is provided by an employer or is a personal policy or is a medicare supplement or medicare HMO? The absolute first thing you need to do is find out where you stand in regard to your policy. You need to find out if it is a covered benefit and if it is a covered benefit exactly what are the requirements. You should be able to get that information from either reading your policy book or calling them. Once you know where you stand with your insurance then you will know what you are up against. If it is a covered benefit and it is a matter that your BMI is too low and you need an exception-- that is one thing but if it is not a covered benefit and you are trying to overcome an exclusion that is another matter entirely. OH has a standard letter of Medical necessity posted at the following link. You can copy and paste this letter into word or worperfect and then tailor it to your situation. http://www.obesityhelp.com/morbidobesity/information/wlsjourney/letter+of+medical+necessity.php There is a sample appeal letter (although I am not sure you are at that point yet) at http://www.obesityhelp.com/morbidobesity/information/wlsjourney/insurance+trouble.php As I said before try posting this on the main board. There is a wealth of knowledge out there and some very generous people. I will continue to look for other letters and if you will provide me with more detailed information I will try to help. This is not to say that someone with medical or insurance experience need not step up to the plate. I have neither medical nor insurance experience, consequently, I am not qualified to advise you in any way. This will be the blind leading the blind. But if there is no one with experience it least you can bounce ideas off me and I might be able to help with wording and format and general "stuff" like that. Red

Mystic I too have Humana Gold Classic. My BMI is 75. I just checked Humana's Surgical Treatment for Sever Obesity. It states a BMI of 40+ or a BMI of 35 with Problems. Good luck but it doesn't sound good. Mike

I don't know if I saw your initial plea, but I have 2 letters on my profile you can look at. However, your BMI isn't even 32 and I would say that your chances are probably slim to none to get your surgery covered. You are practically in the "overweight" category and only barely in the "obese" category. Most, if not all, insurance companies would expect a patient to be morbidly obese in order to cover surgery this drastic. I don't mean to preach, but this surgery requires a huge change in lifestyle. I hope you don't consider this an easy fix. I guess I'm thinking how I might feel if I were you. I wonder also if you have a surgeon that's already agreed to do a bypass on a patient that has relatively so little to lose?? I hate to be a negative voice, but I wonder if you might consider doing more research on this. Jan 240/126/115

You always say what I am thinking, Girlie! Amy

Amy, funny how that is, because you always say what I'm thinking, too! I hate to burst anyone's bubble and I don't want to seem mean, but people told me that I didn't need this surgery also and I had nearly double the amount to lose as this lady. I think 70 lbs. is a lot of weight to have to lose, but I also think it might be manageable without taking the VERY drastic step of major, permanent surgery that brings on a whole bunch of risks in itself, especially when you consider that the original poster says she's already got serious heart problems! Although I don't speak for my surgeon, I believe he wouldn't touch someone with that little to lose because she would lose too much following RNY surgery. Lap band may be a better choice as it's less invasive, less drastic and the loss is much slower. I wish anyone luck in losing unwanted lbs. that affects day to day living!! Jan 240/126/115 (at goal size)