Discouraged

Hello all. I am so so so sad.  I submitted everything to my insurance.  The first time I was denied so I filed an appeal.  The reason for the denial was no medical supervised diet.  So my PCP sent to the insurance evidence of supervised diet.  Denied again this time they stated not medically necessary.  OMG are you serious!!!! That is what I said to myself.  So I called my PCP and she stated that I should think about changing surgeons because she noticed that when WLS is submitted by that surgeon they usually get denied.  So she recommended Dr.Roye.  I called the office and made an appointment.  But in the mean time I called my insurance company to request a hearing. Can you believe they told me it was a waste of time because I will need to submit new evidence of it being medically necessary.   I'm trying to avoid geting high blood pressure, diabetes and strokes(mother's side), all of which runs in my family.  I've tried diets upon diets and nothing worked.  I don't want to get to the point of having diabetes, high blood pressure before getting the surgery.  I don't know what else to do.  Has this happened to anyone else?  What did you do about it? Also, how is Dr. Roye? All suggestions and comments would be gladly appreciated.

First, I am very sorry about the denial.  i am in the process of getting approved, but I am having problems too.  They have not said I am denied yet, but I cant help but feel like it is coming.  The lady at my insurance told me that I basically was not "fat" enough.  140lbs overweight, and not fat enough.  Because I dont have any other health issues, it has to go through a whole bunch of departments to be reviewed.  If I was 200lbs overweight, she could have approved me on the spot.. Second.  I really like Dr. Roye.  He was down to earth and explained everything in great detail.  I feel great knowing if he does my surgery that I am in good hands.   I just wonder what he can do to make it look "Medically Necessary".  Good luck, and keep your chin up. Jen

I don't know why she would tell you to change surgeon, It doesn't matter who submitts the request they always try and denied it the first couple of times. You should have your primary care doctor write a letter to your insurance and tell them your family history.I believe that will help, my primary did it for me and it worked.

what kind of insurance do you have?   I work with insurance companies at my job every day.  Some are definately easier than others.  I have Blue Cross Healthmate Coast to Coast.... approval was the easiest part.  I do have "co-morbidities" though.  Have you been checked for sleep apnea?  that is a huge one.  History of heart disease or type II diabetes?  I just don't get insurance companies that would rather have you put yourself at risk later than help you now when you're asking for it. just my 2 cents Pam

I have United Health. I was thinking about writing a letter of appeal myself.  Not sure if that would work.  UGH!!!  I couldn't figure out why changing surgeons would help out my situation. The only thing I would figure is that they are friends  (she talks very highly of him.  When I told her I wanted WLS she told me to go to Dr. Roye because that's who she's dealt with and the patients had a much greater success with insurance approval).  

Not sure if Doctors should make the difference and you need to make sure you are comfortable with the person you go to.  I have heard good things about Dr Roye so I am sure you will like him.  Part of the insurance process was for my primary to not only write a letter saying that I am healthy enough to undergo the surgery, but that they recommend the surgery for these reasons: diets in the past, family history, this much over weight, and she also said that I was unhappy about being overweight.... Good luck - hope it works out.

I don't have united health, but from what I have heard, they fight everything.  My mother kept getting very serious throat infections/irritations.  For 3 months every year she would completely lose her voice.  She went through test after test, found part of the issue was how she was using her vocal cords in speaking (weird- she speaks very normally) and needed speech therapy.  This again was medically necc, and could lead to possible cancers of the throat if not done.  She was denied for this and had to self pay.  I would check to see if you can search for people by insurance providers, contact people locally with united and see what hoops they had to jump through.  Fingers crossed for ya!!!!

I LOVE DR. ROYE AND HAVE BEEN HAPPY WITH MY CARE. IT WOULDNOT HURT TO HAVE A SECOND OPINION AND SEE IF THERE IS A WAY HE CAN GET YOU APPROVED, ITS WORTH A TRY ISNT IT   MSPARIS