Is there any hope???

I am writing this for my mother. She is 5'5" and 296 lbs. She has DM type II, sleep apnea, osteoarthritis in both knees and left hip, high cholesterol, HTN, and depression. At times she has to use a can to walk and can only walk short distances, she see's an orthopaedist for regular cortisone injections into both knees and has a handicap placard. She has BC/BS of ILL-PPO, she started the pre-op program in June 2004. She received her first letter in Dec 2004 stating they needed more information. After getting complete medical records from several physicians she again submitted her claim in April 2005 and received her first denial in July 2005 stating they had not received her medical history from PCP. AUGUST 2005 she had medical records submitted from PCP only to receive her second denial letter in Nov 2005, stating that she didn't have documentation supporting a physician monitored weight loss program and exercise program. I dont understand how they can keep denying her claim with all of the co morbities she has along with diagnosis of morbid obesity. Does anyone know how what route she should take now? Is there someone I could call or write to and do you have an address? It tore at me when she called me with the news that she had just received her second denial letter. I felt helpless because there was nothing I could do for her. PLEASE HELP Angie

Hello, Angie...ever consider hiring your mom a lawyer....this is sometimes the last resort to go to....But, they can actually make it more easiler on your mother and make sure all the i's dotted and all t's crossed....Just a thought....G'luck hun...

I know EXACTLY what you're mom is going through. I am walking in her shoes too. What to do? First talk with the Surgeon and ask for a Peer to Peer review. This is where the physician talks to the insurance company on your mom's behalf. Sometimes if the surgeon feels this surgery cannot wait there is a possibility they may waive the weight loss attempts or at least part of the required time. Thats a maybe..... Now you say your mom has handicap plates. Those are difficult to get so she must be considered handicapped. Have you used the Disabilities Act with the insurance. In reality your mom is going to have to show some kind of weight loss attempt. If she has none, then she needs to talk to an attorney, and or start one. I know you feel bad for your mom, but keep in mind how much red tape and beauracracies there are in this field. I don't understand why they think we should spend another year wasting precious time. Good luck. Barb

Where there is fight there is hope - encourage your mom to keep on fighting. Insurance companies will drag the process out just to get you to give up. Hiring a lawyer can help. I hired one to represent myself and my daughter in 2003/2004 and he got the job done. I don't think that our insurance would have approved our surgeries without our lawyer working the appeals with us. Though a lot of the WLS clinics will assist you with the insurance fight most don't considered it their responsiblity to get the approval for the surgery. I know how draining this process can be for you and your Mom but you both have to stay strong and determined. There are many lawyers out there assisting in fighting this type of battle, many offer payment plans and options to assist with the legal fees. The lawyer I used is named Walter Lindstrom (he has had WLS) and is based out of California. Just look him up on the Web - www.obesitylaw.com or search out some of the others out there. Good Luck, Sherrill

Well there may be..... Today I heard from a nurse that when a person is severely morbidly obese and has at least 4 comorbidities, a diet attempt may be waived. That is if withholding the surgery is an endangerment to her life. The key here is to get the insurance rep at bcbs ppo involved and talk this through calmly, ask them for help and answers as to why they would deny this procedure. Then request bcbs to speak with the PCP and or surgeon and stress this is a medical necessity and could be an emergency if something is not done. First call the Doctors involved and ask for their support. Call BCBS and ask for that phone consultation and for an expediated review. What you have to realize is bcbs is bombarded with thousands of people who are not or who have not tried to lose weight the conventional way. A doctor is not going to lie to an insurance company. Establish a good repour with both ends and hope for the best. I wish you luck, be calm, patient, honest, and be an advocate for your mom. Ask BCBS what they can do to help her.