Denied--again!

How come every time they send you a letter of denial, the reason is that you haven't complied with some requirement they never mentioned before? Why can't they give you ALL the information the first time? THIS time they say it's "not medically necessary" because I didn't go to a dietician once a week for six months. The word "dietician" was never mentioned before- ever! Nor was the word "weekly." It's like trying to hit a moving target. I'm trying to collect articles about the potential for weight loss surgery to reverse diabetes, and the costs of treating diabetes complications down the road for however many more years I live. If anybody knows of any such information, I'd appreciate it if you could share it. Thanks!

Start going to the dietician. If nothing else, it'll help you learn about eating. Also, if you haven't submitted it, the ASBS has something called "The Rationale for Bariatric Surgery" I highly recommend EVERYONE include that with their submission to insurance. Try to keep positive. If this is something you really need...you are gonna have to fight for it! Good Luck Melissa

Gail - I just read your profile. I have the same insurance you do. It seems that 1/1/04 they added the six months of a doctor supervised diet AND six months of dietician visits. They do not cover the dietician, be aware of that. I am almost three months into my dietician visits. I was denied because I needed that and a few other things but in general was told if I do the dietician thing I will be accepted. I am keeping a positive attitude and going to the dietician and the doctor. It is getting old but I keep telling myself that it is not forever, just for six month. I can make it, I will make it. Tell yourself the same thing. If I can do it, I know you can. You can email me and we can "talk" regarding our insurance and their wonderful requirments if you would like. Good luck, Nancy

Thanks, ladies! Nancy, did you mean 1/1/04 on the diet-history changes, or 1/1/05? Cause if it's 05, it seems to me that since I started this approval process last JULY, I should not have to deal with new rule changes? Anyway, right now I'm putting together a letter to them, highlighting the fact that I have diabetes, which in itself makes this medically necessary! I'm sending a bunch of articles about the 95% rate of reversal of diabetes post-surg. P.S.- I've spent most of the last seven years in the dietician's office! I doubt there's much more to learn about "eating." It's not that I don't know how... well... you all know what I mean! Gail

No, unfortunately I mean 1/1/04. I started my quest for approval back in 9/04 and they told me that they had changed the requirements back in January. There is no way around the three times a month in the dieticians office unless you are willing to hire an attorney. I looked into Obesity Law and they claim that they could get me approved but the cost of hiring them was to cost prohibative to me. Therefore, I go to the dietician or the doctor once a week. I am half way through. I am hoping for a summer surgery. I just hope once I finish the dietician/doctor visits they do not add any additional requirements. I do know that besides the doctor/dietician thing you need a psych exam, a bmi over 40 for at least three year or a bmi over 35 (for at least three years) with at least two or three comorbidities. Good luck, let me know what is happening. Nancy

Boy can I relate to your frustration! I talked to my insurance company several times, trying to get a straight story from them. Every person I talked to had a different set of rules. The surgeon's office (Barix) referred me to Walter Lindstrom from the Obesity Law and Advocacy Center (www.obesitylaw.com). They took on my case and four months later I had full approval. They sent a huge letter in for the appeal, and then represented me at the hearing. Walter's office was wonderful, and very helpful. Barix took care of the fees for me, so it didn't cost me anything, but I know that they will work with you to make it doable. Don't give up!!