I need advice on appeal situation

I had bcn hmo for three years and was denied three regular submissions and two appeals, for the same reason faliure to follow a 12 month weight loss program. I did exactly what they said for 12 months and was denied again that is when I decided it was no use! I had to wait til open enrollment to switch to reg bcbs but then I got a new job and united health care insurance. I know you dont have that option so here is my suggestion to you definatley get refferal for the WOW program that helps Hap see you are doing what they want you to through and the decision of switching of PCPs can help or hurt so that one is a toss up I thought about the same thing when I had the same struggle you could end up with a better pcp or worse one so investigate the pcp find out if the doctor see's patients who have gastric bypass surgery (do it annomously ) maybe by calling and asking the receptionist if the office sees post op gastric bypass patients (just an idea) if they doc does then it could be a way of knowing that the doc stands behind gastric bypass sugery and will be supportive. How was the current PCP did they write a good recomendation for you ???? Its a matter of pros and cons go on here and ask for some refferal doc names of people whos pcp supports the surgery and you will be amazed how many people will give the names and numbers of their pcps. Then you can choose the closest one to you. You are right about getting med records get the records from all dr's seen in the last three years. Even specialists. I hope I am helping in at least a tiny bit. I can totally relate to you I was there and it was living hell I just wasted almost two months on a weight loss center who dragged there feet and did nothing In one day I accomplished more than I have in 7 weeks with the other program please email me and I would love to help you and listen to you and give you support I would even call around and help you I have free long distance and I am good at cold calling and asking questions for others I help my friends and family memebers by calling places they are too timid to call. Email me and lets make some progress they have me off work till 2/8/06 cause I am having trouble walking and driving but I would like to make some calls and help you get this ball rolling faster. If I am being to forward I am sorry I just wish three years ago some one would have offered me some help [email protected] Angie Paschall email me I am really willing to help if you dont feel comfortable I understand You are in my prayers. DONT GIVE UP THATS WHAT HMO'S WANT YOU TO DO MY NICK NAME FOR BCN IS DONT CARE NETWORK. THEY WANT YOU TO GIVE UP SO THEY DONT HAVE TO PAY.

I would let my surgeon appeal, but I would also send a letter via FedEx to your insurance co. detailing all your health problems. I also let them know that if they did not reverse their decision, I would seek the advice of an attorney skilled in these matters. Three days later, they set up a phone conference with my surgeon and approved it that day. I also got a letter from my regular MD as well as a letter from a anotehr doctor I had seen for reflux (stomach specialist) as well as my surgeon. The more doctors you can get behind you, the better. My insurance co. invited me to be in on the phone conference, but my doctor said no, he would handle it. And he did! But, I would make sure to call the surgeon's staff about the appeal and bug them. They are swamped and sometimes miss things or forget to fax things. Take it into your own hands and become polite but forceful with everyone, even your doctor's staff. It is your life and your body! Good luck to you and God Bless!

The surgeon's office is a dead end. They will not even set up a consult until I get approval from HAP, so I have not even seen them yet. Unfortunately, thats the rules of the game, approved by insurance before they can set up any appointments with the nurse/dietician or surgeon.

Colleen... email me at [email protected] and I will send you waht I did for my appeal. My denail was diffrent from yours, but maybe it will give you some direction. Erin *Insurance WARRIOR always!*