HELP! Confused!! Insurance Denial Info

Here is what I received from my insurance provider.......Based on their report, "The patient is an emotional eater and a binge eater. "She feels disgusted, depressed, guilty after overeating." This is typical compulsive behavior towards food and needs to be addressed and corrected before surgery is contemplated. These recommendations were made by the psychologist as well. Even though there are references to various diets that the patient followed for short periods (usually only a few months), they are not physician supervised and lack the multidisciplinary, behaviorally integrated effort as suggested by the psychologist's recommendations prior to the surgical procedure. The services are not medically necessary as she has not participated in a comprehensive, well defined, physician controlled program of weight reduction, lifestyle change, behavior modification, and support, and as her aberrant, compulsive eating habits need to be addressed and corrected before any surgery is considered." This is what the letter from insurance stated. I thought everything was fine with the psychologist and he gave me the green light. Now I'm really confused why there would be a statement like that when it wasn't even talked about in our sessions. I have American Community insurance through Sagamore.

Amy at Dr. Clark's office said she had never seen an insurance company pick something like that out of the eval and have it denied. Great!! Of course I had to be the first one. Regina

why i have never, and i run a board on yahoo for cigna ins...and cigna sucks and they have not picked apart a denial like this.....does not appear to be the issue. you may over eat a time or 2 after surgery but your gonna learn real quick no way.....why it is important to measure and eat slow and chew chew.....i sent you a private email to email me and i will send you garys link...

Take the letter back to the psych Dr and ask him about his report. If they have taken anything out of context, he should know. Cindy

I spoke with the psych doctor today and he told me we can resubmit the info explaining the problems I had when I came to him at first and how we have worked through them since. Apparently there was a sheet that wasn't supposed to go to the insurance company that can indicate red flags to them from the evaluation that was sent to them against the psych doctors recommendation. So much for that.......anyway.... I have to start seeing my family doctor and be under a doctor supervised weight loss plan. The insurance told me they didn't have any requirements for how long I should be on this plan except for it may work in me loosing weight and I won't have to have the surgery. Regina

I saw the psyche doctor yesterday and he said there wouldn't be any problem to submitting an explanation of what he wrote about me and how we have worked on correcting some issues. I have to admit when I first got the letter and saw the statement, "she is a binge eater and feels disgusted, depressed and guilty after overeating" it didn't make my self esteem much better but the more I thought about and it and the support I get here on the message boards it made me strong to say I wasn't giving up and I wasn't going to keep quiet. My health is worth much more than just giving up and keeping quiet. Hope all is well with you on your journey and you've gotten your energy back. Who would have thought od'ing on calcium. Regina

I'm glad the psych Dr is going to help you. I'm also glad that you are willing to fight for your right to improve your health. You deserve it. I know the diet will be a pain, but it will actually work in your favor. It will help you learn to make better food choices. This is something you will have to learn after the surgery anyway. It has been my experience that having over 18 months of "practice" before the surgery has made it easier now. I was diagnosed with type 2 diabetes in August of 2004. I immediately looked at wls because my doctor told me that if I could just lose weight, it would go away. At that time, it seemed much to drastic a reaction. I couldn't wrap my mind around the changes they would make to my insides (I had the RNY eventually). And the idea of having to completly change the way I ate seemed impossible. Logic dictated that if I could do that, I wouldn't need the surgery! However, after having to change the way I ate to control the diabetes, I went to the seminar on wls in August of 2005. Following my diabetic meal plan not only prepared me for the choices I would have to make after surgery, it satisfied the insurance requirment for a doctor supervised diet! So, no, it wasn't any fun to have to follow that diet. But it was what I needed to help me prepare for my new journey. I am doing well now (thanks for asking). I was able to flush the excess calcium from my system and I'm back on a normal dose. My energy level has returned to normal and my blood pressure has stablized. The dizziness, light headedness and shortness of breath are all gone. Next week I'm going to start working out again. I've been taking one flight of stairs a couple of times a day at work, since I wasn't working out. I'm going to work my way up to climbing from the first to the fourth floor eventually! I am 8 weeks out today and down 40.1 lbs. I am very pleased with the results and hope you start your journey soon. Cindy