First appeal with Group Health- any suggestions?

All I wanted was a referral to meet with the surgeon and THAT was denied. I am shocked they won't even let me meet with the surgeon to go over the requirments first before just appealing. It's almost like they have to appeal. I'm with Group Health and not really happy about my limited choice in surgeons anyway and I live in Tacoma and would have to go to Overlake Hospital in Bellevue. Pretty far from home. But now it seems like I can't even go to the surgeon I don't really want to go to in the first plave. Anyone else out there that has gone through Group Health and can give me some advice? Please Help!!

Hi Holly,
    I am GH also, and had Dr. Landers with surgery at Overlake. I was thrilled to get this Doc. After meeting him, and researching his work (Cleveland Med. Ctr), I was very comfortable. The hospital was amazing, and the entire floor is predominantly wls patients.
   Regarding the approval process, I had co-morbidities (HBP, sleep apnea, high cholesteral), not to mention a SMO bmi.
  I basically just asked my pcp/pa for a referral. She sent me to a dietician, then submitted my request for surgery.  Did you talk to your GH PCP? Maybe you should talk to another doc at GH for referral. Mine was actually done by a PA and not the doc they have listed as my primary. I preferred a female, and the PA was my only choice in Port Orchard.

Good Luck and Hang In There!
Kathy         

Hi Kathy. My PCP is the one *****quested the referral. Maybe I'll try going to the PA next time. I have PCOS, sleep apnea, high cholesterol, and have been to the Dr about 100 times in the last year alone (including Urgent Care visits) for low back pain which is large and part caused by my stomach fat. I am still waiting for my denial letter so I can find out what I need to do to appeal. Keep your fingers crossed that I can get this done sooner than later since I probably won't have any insurance after Jan 2010. Thanks!

Hi Holly,

I am also with GH.  About two years ago I just asked for a referral to Dr. Bock.  At that time, I was only being treated for diabetes.  GH denied the referral.  Then last year, I was referred to a rheumatologist for examination, which turned out to be nothing other than complications from my diabetes.  The doctor suggested that I discuss with my PCP about the possibility of referral to the Bariatric Program due to my co-morbidities (diabetes, and now high cholesterol and high blood pressure) and I received a letter in the mail shortly after accepting me into the program.  Although my BMI is 35, they approved me because of these chronic illnesses associated with obesity.  Talk  to your PCP or his/her PA about getting a referral to the program.  At that time, the doctor's nurse can answer all of your questions.  I've had pretty much all of my tests done.  There's a lot of criteria you have to meet before getting a surgery date.  The program also requires you to enroll in the Advantage program, which is going to cost approx $1,450, and they require enrollment no later than 10 weeks prior to surgery.  Also, Overlake is a wonderful hospital.  My husband was hospitalized there when he suffered a serious injury.  He almost died, but the doctors and nurses at Overlake took very good care of him.

Good Luck!

Thank you so much! I think I will have to go with Dr Bock as well. How long did you have to be enrolled in the Accomplish Bariatric Program before you could schedule your surgery? Did you have to pay for the 1 year program or did you have the option of buying the shorter term? It does seem like a good program.

About 8 weeks before surgery you have to sign up for accomplish.  I started Dec 10th and had surgery Jan 28th.  Yes had to pay for 1 year.  No other options.  If you are on medicare, you don't have to pay for it.

 

 

Hi Holly.  I too am with Group Health.  I was approved on the first try.  Have you tried talking with your PCP about co mords, I think they will approve when you appeal.  Which surgeon are you not wanting to go in first place? Dr. Landers is very good surgeon. I had surgery almost 3 months ago and I'm doing well and so are other GH patients. 

Good luck and keep on appealing!  Keep us posted!

Hi pixiestix! Thank you for responding to my post. Is Dr Landers with Overlake hospital? I was told I had to go there and I only saw 2 Dr.s listed that do bariatric surgery. Neither seemed to have much experience. Thank you for the hope you have given me. I am still waiting for my denial letter so I can't appeal until I get it. BTW- What are co mords?

Yes Dr Landers is with Overlake, but he works for Group Health.   Group Health Bellevue  medical Center is right next to Overlake, and Group Health has contracted with Overlake to use their facilities.  All WLS patients from GH get their surgeries at Overlake.  I already told u a little more in the mail. 

Co mordibites are health issues related to weight, such as arthritis, sleep apnea, diabetes, etc.  I have diabetes, sleep apnea and slightly high cholestrol.

 

 

Well, I got my denial letter and they said I don't qualify as medically necessary. It seems I don't have the co morbidities that they want me to have. DARN! I have an appt with my Doc tomorrow to talk about whether it's even worth appealing it or not. I am 295 lbs have PCOS, high cholesterol, insulin resistance, mild sleep apnea, and SEVERE low back pain that has lasted for 3+ years steadily. I don't know why that's not enough!?

Well, we'll see what happens next. I am so frustrated!