SOOOOO upset!

I'm so upset, I need to vent. Where my husband works, they have an exclusion in their insurance for WLS that states you have to have two consecutive years of specific documentation. I'm ok with that but I don't have it documented the way they say they want it done-I've been dieting for over two consecutive years (physcian monitored). I was also told by the surgeon at consult that in two year's time, he would not consider me a candidate due to my co-morbities, etc. My physician and cardiologist have written letters and sent in my records but the insurance department won't submit stating I will be denied. Yes, I know this but... So, I call my husband's employer benefit department and explained my situation. I didn't know at the time but my husband was doing the same thing. We both got the same answer from different people. They strongly suggested I insist they submit and then appeal as when it goes into the appeal phase, they look at the whole record, including letters, etc. They said that exceptions can and will be made when it fits. They told my husband that MANY cases would be approved if they followed through and submitted and went through the appeal process but many insurance departments at physician's don't want to deal with the paperwork. I then call the insurance company itself-patient review/case management. I was told basically the same thing. It needed to be submitted, exceptions have been and can be made and if I couldn't get them to submit it, I should consider changing surgeons! Something I really didn't want to hear! He told me I had the legal right to get them to submit it on my behalf. I left messages last week with the insurance person to call me to discuss and nothing. Finally yesterday, I called and insisted she contact me. The last she had told me was she would need to discuss with her supervisor if they had enough to submit. She finally called me today and tells me no way would they submit-it would be denied-and the appeal process wouldn't work. I was so upset! She has told me she has literally hundreds of patients who are on hold because they don't meet the primary conditions and then today, she tells me hundreds have been submitted and denied from my husband's employer-that the insurance company just tell you to appeal to appease you! With that, I told her to send me my records. I made an appointment with another surgeon today. I go on Monday. I'm so upset that I've been wasting my time for over 4 months now, gone through surgical clearances and I've gotten no where. I wouldn't mind meeting the basic requirements but my health will not last that long and the end result would be I would no longer be a candidate and they end up with a stack of papers saying I met the requirements. Has anyone gone through this before-where they won't submit? Sorry this has been so long..... Beth

Hi Beth, I was reading over your profile & saw that your surgeon of choice is Dr. Adolph @ BTC in Groveport, I have chosen Dr. Maguire in Kettering, Ohio. I read over the comments that others have made about Dr. Adolph & he sounds great but that isn't going to help you out if he doesn't have a staff that will support you in this process. I have heard good as well as bad things (as I am sure you have too) about BTC & it has been said they are a cookie cutter type place. They apparently have their process on how they handle submittals & don't seem to budge on that. If they won't help you, you owe it to yourself to find someone who will. I am in the appeal process right now (I have Med Mutual) for kinda the same reason you are facing. I do not have much in the way of documentation other than one prescription for diet pills from PCP. Everything else that I have tried has been on my own such as Weigh****chers, Atkins etc. I am submitting credit card receipts, cancelled checks & anything else that I can muster up to help my case. I can only offer my support & tell ya I know how you feel. Nothing is worse than when you finally decide "okay, I am going to try this avenue to prolong my life" & then you reach the roadblocks. Jen

Hi Jen, I was reading your post and I too have Med Mutual and virtually no documentation for a history. I am very fearful they will deny me. Is that what happened w/you and then you appealed, submitting everything you can find?? Man, I'm doomed if that's the case...like you, everything I did was on my own too. Any advice?? thanks..

I feel really bad for you. I never heard of a company or office who would say that. They only want the quick fixes apparently. You are better off with out em.

OHHHHHHHHHHHHHHHH BTC in Groveport actually I had the similar thing happen my insurance wanted a 12 month physician followed diet and I did not have that however I called my insurance company and they said the same thing exceptions have been made and these were merely guidelines not specifications so I was told to submit anyway like you were told I called BTC and argued with the insurance person and evedently said the right thing because they agreed to submit without the diet I gave them the name of the woman at my insurance company and that it was noted in my file at my insurance anyway I found the BTC to be kind of impersonal and over booked I was there for quite a few hours and saw him for 10 minutes (the surgeon himself was so nice) however I was not impressed with his snobby staff I felt like they were in it for the money and not for the patient well to make a long story short I found a new surgeon and I love him He was the first surgeon (I met with 3 others) that I really felt like cared about us and our problems and from what I have read on profiles and message boards helps with appeals and tries to help people have this surgery BTC in Groveport when I was denied the first time just said well they denied you and I said what do I do now and they were like I don't know it says does not pay for weight loss guess nothing.........and when I was there they said they will do what ever it takes to help me and well when it said denyed that was that anyway yes I am glad you have a new surgeon and I am glad you are not giving up I kept trying and I now have a surgery date so do not give up ever prayers and hugs