predicament

Here's where my situation stands now after being denied a second time. The insurance rep informed me the information I sent did not show that all measures were taken in the past regarding dieting. Also, supposidly that there was no proof of me being obese for the past five years. I informed her the paperwork from the doctor at that time (which is different from my current doc) shows my weight at that time. She recommended my current doc, who supervised my six months of dieting recently call for a peer to peer call with one of the insurance physicians. Well, my current doc really hasn't been enthusiastic about me doing gastric bypass, infact she pushed a doctor in the area that is doing clinical studies on various diet drugs. I asked her to call the peer to peer line and she's dragged her feet since thursday. I received a voice mail from her yesterday saying she has the name of the doctor that does the clinical trials for the diet drugs (she couldn't remember his name before) and she will call the peer to peer on monday if i really want her to. My predicament is that I don't know if she will say she is in favor of it and I need it or will she say she's not and that she wants me to do the diet pill thing. I could talk to her about what she's going to say prior to her calling them, (hopefully) or I can tell her to not do it and send additional paperwork from like my orthopedic doc who did a knee operation on me five years ago (being heavy didn't help he said), send them copies of the diet outline the dietician gave me several months ago when I started the six month diet thing that the doctor saw me for monthly (but really wasn't saying much to me about it at each visit). I know this is winded but I really don't know what to do. If she is positive with the peer to peer thing than the appeal process is speeded up and I will more than likely be approved within 24 hours OR I can chance it and submit a few more things. Several months ago she did send a letter with the initial packet stating that the gastric bypass will help me but she didn't say she thinks its a positive thing for me. Again, I don't know what to do.....please help. Thanks!!

Oh Stacy, what a mess. Don't know if this will help you or not. My orthopedic doctor was the one *****ferred me. But I also had records of where I had tried weight loss before and failed. One of my co-workers tried to talk me out of surgery and to go on the new diet pills. When you quit taking them, then what? I think I would be right where I am now or bigger. Good luck with your approval. Will the office of your surgeon help in any way? I know mine was great, but alot of it depends on the type of insurance you have. Let me know what happens. I have surgery on April 11. Hope you get some answers soon. Hang in there. Alice

Alice, Its great to see someone close to me having surgery. Where are u getting yours done and what type are u having. I will be at St Vincents on the 13th if u are there recovering I could stop in and see u too???? Pamela

I'm getting my surgery done at St. Vincent Carmel. Sure you can come see me. Where do you live? I live in Winchester and work at the St. Vincent Hosp there. Who is your surgeon? Mine is Dr. Inman. Get on my friends list so we can keep in touch. Alice

Thanks Alice. My gastric doc's office has been helpful but I haven't asked them what to do. Maybe I will tomorrow. I agree with the pill thing. I've been there, done that and gained the weight back and more. And there is no guarantee I won't be on a placebo. PLUS, if I were to get some diet pills not in the clinical trials my insurance does not cover the cost. So, I will be telling the doc about that yet again!! My husband is getting the procedure in April and I want to be doing it in May. And he was approved on MY insurance!!! Isn't that the best?!!!

well Stacy you might try getting together pictures of yourself over the last five or so years and send them in, if like me tho its hard because we never like getting them taken but it happens . candid shots are the best . i had one so i had to call family members to get some i didnt need them but sent them anyway . just in case. heck its worth a try and they will send them back if you write a note to that effect. good luck vicki

Stacy, You indeed are in a tough spot. Does your husband go to the same Dr. that you do and was it paperwork from her office that was used for his approval? I think it is time for you to make an appointment and go in and have a face to face with your doctor. Be nice but don't be a push over. Remember you hire your doctor. She works for you. It is hard for us to think along those lines but that is indeed the case. You need to ask why she is reluctant to support you in WLS. Has she seen the research and studies done that show the success of WLS vs conventional diet and drug therapy. Bariatricbytes is a website that has some good info you might want to go to and get some studies for your Dr. to read. WedMD is another site that has studies she could research. Mayo has done some good research as well. Look through this website and see if you can find some info. Ask your surgeon for some studies to take with you. I think you need to hammer her with the research and study aspect since that is the direction she is wanting you to go. She is asking you to consider joining a pharmaceutical clinical trial. As you most likely know, this would be taking a drug that is not yet proven to be safe for the general public. You would have to sign an informed consent just to be part of this. Let your Dr. know that you are not comfortable participating in taking a non-FDA approved drug due to the unknown side effects whereas bariatric surgery is an FDA approved treatment for obesity. (I am a nurse and work in clinical research and I would not consider doing a pharma trial unless it was for an incurable disease with no other treatment available but that is just my personal opinion.) I would also encourage you to get some info together on your own. Get one Dr dictation or written note from each year for the past five years that has a recorded weight on it. Vicki's idea of a picture journal of your weight is also a good idea. Remember you can ask to see your chart or have copies made out of your chart. Send this additional info to your insurance company prior to the peer to peer call. As far as the peer to peer call -- I would have my face to face with the dr first to see if she is going to be supportive. Also it is within your right to ask if you can sit in on the call. She may say no but you can always ask. Remember be nice and be respectful but also stand up for yourself. If you don't -- no one else will. Best wishes. Let us know how things go. I have my fingers crossed for you!! Peg

I can only assume you have BCBS for your insurer. They denied me twice. Although at the time my BMI was under 40 I had HBP, Sleep Apnea, Hypo-Thyroid, arthritis in my back. All of these things were never really taken into consideration. With insurance carriers and physician's we always feel like a number. I truly don't believe the claims adjusters even read through half of what they ask for. Why doesn't your surgeon file the claim? I know my surgeon's office needed to gather medical data form my primary care physician and then sent in the claim. I wrote a letter and sent pictures and it didn't help because my numbers just didn't match what they're told to look at. I switched insurance companies and was approved within a week. I think the peer to peer call should be between your WL surgeon and the insurance company. not a family dr. where obesity is NOT their specialty. JMHO, Judy