Denied - but with conditions to be approved.

Well, I've been denied in my pre-authorization. Despite the fact that I've been through a 1 year MD monitored weight loss program, and tried Xenical, and every other diet out there, I was denied. The reason being that these did not occur in the past 1 years time. My insurance said that I've got to show 6-12 months of a medically managed weight loss program and still be morbidly obese. This has to occur in the past 12 months. I started the program in July, and have been to the dietician, exercise phys. and shrink already, but I guess I just don't have the time done yet. This is a real bummer, because we'd just hit our deductible for the year ($4,000) and it seemed that all the ducks were in a row. This puts me in a quandry. If I continue with the dietician, MD visits and exercise I will be eligible (by their rules) sometime in February. But what if I lose 10# by then, will they say - "nope, you're not failing" and deny me again? I know I can lose a few more pounds, but inevitably they just come back. That's why I'd decided to do this surgery - to change my eating habits for good, with some help. So, now what do I do, it seems that I'm damned if I lose weight, and damned if I gain. Anyone out there have this experience? Right now I'm going to have to wait until monday, when the insurance gal is in the office - maybe she has some insight or knows how to get around this sticky situation. The funniest part of all this is that today on the phone with the insurance the gal said "we just want to make sure you're not doing this for cosmetic reasons". Yeah, right - cosmetic reasons are my reason - NOT, it's the High Blood Pressure, the sleep apnea, the high cholesterol, borderline diabetes, arthritis, and GERD that are really my reasons!

When you send in your appeal send a picture, a personal letter and explain the side effects of Obesity..HIgh BP, Knee pain,diabetes, arthritis, and GERD and if you dont qualify if you loose 10 pounds.. humm... would that make your BMI THAT much less? Linda

i would write an appeal using all my health issues as to why i need this.....i would first call Gary and see what he says he will know about your ins and your state......he will be able to tell you to appeal or to finish your one year....... i do know in appeals people have won by saying the NIH says these diets do not work..and any weight loss in this time is fine........shows you are able to do it and show discipline....i lost 30 pounds......and was 30 pounds i did not have to lose after my surgery...... appeals are very stressful, all you can think of till you are approved or denied again.. wish you luck and keep us posted as to what they say......

I was wondering the very same thing about my MD supervised weight loss plan. What if I lose the weight and they decide I don't need surgery? Aftwer the first month with my MD I lost 12 pounds, and I discussed my concern with her. She said that even if I lost 12 pounds everymonth, and she garunteed me I wouldn't, that I still couldn't lose ENOUGH weight fast enough to not justify the surgery. She also told me to still make sure that I was trying on my program, because they are looking to see if you can stick with the program that your doctor lays out for you, as you have to do this after surgery.I did lose wsome weight during my MD program, but still got approved. Look at this as a time to lose some weight before surgery,m that way when it starts melting off after surgery, you have that much less to lose! Good luck to you!

Actually loosing weight is a good sign for your insurance company to see. It shows them a committment to a better health. They won't deny you for loosing weight, espically if it's only less then a 50 lbs loss in eight months. And your doctor noting the "yoyo effect" of regular dieting will further convince them that without the surgery you are more then likely to regain the weight, regain more weight, and/or regain without the assistance of surgery. I lost 50 lbs during my insurance process, but because of the "yoyoing" my doctor noted it really showed my insurance company that without surgery I was NEVER going to be successfully healthy and lower their cost of all my medical bills/supplies (you can address that part in a personal letter to them also, I did.). Good Luck. Hang in there. This part (argueing with the insurance company) is the most frustrating and has a tendency to bring the emotional turmoil to a head... but hang in there. It's worth the fight. Jodi