Optimum Choice "Clinically Denied" my first submission for RNY

I received a call from Rose, the GBMC insurance coordinator Wednesday.  I've been so bummed out about it I haven't even been on OH until today.  I cried twice Thursday just thinking about it.  She got a call saying my request for surgery was clinically denied.  She told me we have to wait for the actual denial letter to find out the reason, but will appeal it right away after that, and keep on it until I get approval.  I do not understand why they would deny it!?  I have a BMI of 51.5 and not just one but several comorbidities.  The optimum choice paperwork I have shows they have a policy that they approve it under my cir****tances.  I am trying to think positively and be patient but I really am very dissappointed.  I contacted all 8 of my Drs who have diagnosed the comobidities and asked for letters of medical necessity to support the appeal.  I called United Health Care/Optimum Choice to inquire about the denial and they said I would have to wait until the denial letter was received, that they could not tell me anything yet, but the doctor could call them and they would tell him.   I was very angry at this point.  It is my surgery,so why can't they tell me the information?    It is very difficult for me to just wait.  I am trying to have faith that this will all work out and I will get my health back.  I MUST have the surgery to get my health back.  I am hoping this is just an insurance game they play and that they just deny it to see if a person is going to give up and go away.  Well I am not going anywhere and I will keep appealing until i get aproved.  I just needed to vent.  Thanks for listening. 

Ok:  first thing    BREATHE ::: Second Don't Panic:  it could be something as simple as  a piece of paper  not received. From what you said I don't see how they could refuse you. 

Wait for Dr. Mo to get the letter :  I am sure he and Rose will know what to do.

 

Darla 

just keep your head up. there will be a brighter side to all this. Just like you said we both be on the losers side very soon.

LaddyV,  Thanks.  Yes we have to stay positive and proactive.  It just gets frustrating when obstacles get in the way.  You and I will be on that "losers bench" they speak about on here very soon I hope. 

Thanks Darla.  Breathing is so much easier today than last week, I tell you.  You are right, it could be that simple and I'm trying not to panic.  You are right, as Dr. Von Rueden had said when I first met him, "You're definitely a candidate for this surgery".  LOL!  I thought that was sort of funny the way he said it.  I do trust Rose and Dr Moein to get my appeal together.  It's just that I'm so close to scheduling and i had hoped to get a date in February.  Thanks so much for your support. 

{{{{Jennifer}}}}} you've gotten some great advice, so all I will say is I am hoping and praying that this will be a short lived detour for you. I think it will be. It's good that your sadness turned to anger. I'm not saying it's good to be angry, but anger translates better to determination than sadness does, in my experience.   I wouldn't  be surprised if this is something that they do automatically, perhaps to see how many people will pursue appeals and show that they are serious. It is most likely just as simple as submitting more info. Rose already verified your coverage before you ever had your first appointment with the COMP team. This will pass.  In the meantime, I can imagine it's very disheartening, but know that you WILL have your surgery and WILL succeed at getting your health back, and we'll all be here cheering you on, and celebrating all the good things to come with you. PM me if you need to vent!

Thanks for the hugs and encouragement ,Kathy.  The support from OH is a wonderful thing.   I just received the first of the 8 letters of medical necessity I requested from my various Doctors today.  That's something. 

Jen - Hang in there, honey!  It sounds like you have all of your ducks in a row, just take great notes whenever you talk to someone.  Waiting is so hard - I've said before that these folks that work for insurance companies don't realize that to us, they're not denying us just the surgery, they're denying us a chance at a new life.  I think if they could see the human side of things, there would be a lot less denials. I'm positive things will work out for you.  Keep your chin up and vent away here, that's what we're here for!  If I can do anything for you, let me know. Tia

Jennifer,  I went through Optimum with my surgery.  Did you include documentation of your 6 months of medically supervised weight loss program? I had all kinds of documentation (6 months of weights watchers cards from the year before.) A current monthly history of weigh-ins with current PCP and documented weight loss attempts in history from my previous physician. (although those ones weren't as consecutive) Optimum is big on the 6 month part.