Why I was denied

I met all the requirement for wls except for one thing......I am not on a cane or walker or wheelchair. OMG that is not a good excuse. My doctor wanted me to get a cane to help me when I needed but I turned it down because Iam 37 years old I dont want a cane. Now I need a letter wrote stating I needed a cane and my doctor is laid up with a broke hip and I cant getan appointment with his replacement until next Thursday. Oh that is my luck, time is a huge factor here and I am gonna have to wait. My luck is terrible, I dont know wheither to laugh or cry...

OMG...   I think that is a new one!!  Good luck with your letter... hang in there.. 

Thanks I think its stupid, I have every requirement but not on a cane,have a walker or wheelchair that is ridiculous.

You really need to get THE copy of your requirements.  Contact your insurance and tell them you need in writing the list... if you don't have them...  and look.  Does it specifically say "insured has to be immobile, on a cane, in a wheelchair, or uses a walker"?  Cause if not, I do not think they are allowed to just make up those kinds of rules.

That is what Heather at Dr. Olsens office said. She said I met all the requirements but I was turned down because I am mobile. I need something saying I am limited in the things I do. I am limited but I just havent went as far as to get one of those things cane,etc. My doc has got hurt and is gonna be out for awhile and I have to see him to get a letter stating that I am limited in what I can do...Thats my luck.

Hi Sonya! I work for a Tenncare MCO. The following is a link to the Tenncare guidelines for bariatric surgery:


http://tennessee.gov/tenncare/forms/bariatric.pdf

If I can answer any questions, please let me know. Good Luck!!!

Kim

 

 

 

OK I just looked over the criteria...  Page 2, number 3 says "Incapacitation of the patient in performing daily activities or disability due to the obesity. There must be documentation of substantial inability to perform the activities of daily living such as evidenced by the use of walkers or wheelchairs"

It does not say that the patient HAS to be in a walker or wheelchair.. if the patient's letter of medical necessity from her PCP states that she has a hindered life from her obesity, and she is not able to perform activities of daily living, should that not be enough?  The language "Such as evidence by the use of...." needs to be clarified because, if they are making those two things MANDATORY, then it needs to say, "The insured must either be (a) in a wheelchair or (b) using a walker."  What if a person does not leave their house, and does not use helps such as canes, walkers, etc...  but they just hurt all the time and lay in the bed?  Can they claim the bed or couch as their "help". 

Kim, is there any leeway in how the determination is made when it ccomes to this point?  I don't know. It sounds "iffy" to me, and definitely open for interpretation from person to person.

Sonya, I would go back to the doctor's office and see whoever is filling in for your doctor who suggested a cane for you.  Get another assessment...  see if your doc wrote notes that  he suggested a cane.  Doctor's offices document the visits, what the doctor said or suggested, etc.  He might even have a transcription service that he called and spoke into the phone, for someone to type his office notes on all patients...  It is worth a try...  

Thanks for the link and the help. It is appreciated.

Thank you so much again, I need all the help I can get.

I agree with Mel.  I think you should insist on a copy of the requirements.   You should have the right to get a copy of the requirement policy for WLS.