I Quit.

5-29-05 I QUIT. Tish, Scottsdale Bariatric's business mgr., called me the other day to say she can find no basis to write my appeal letter. Since I didn't lose the whole 10% during my six month medically supervised diet, I did not comply with Schaller Anderson's (the State of Arizona's) criteria. I told Tish that at the very beginning of the diet, Dr. Emershad said I didn't HAVE to lose the whole 10% (25 lbs. for me). She said if I only lost 10 or 15 pounds, that would be enough to demonstrate my committment to weight loss. I had lost 18 by about the end of the fourth month, but then started gaining it back. They claim no other insurance company is that strict about the 10% loss. It was on the very last day of my six month diet that Scottsdale Bariatric (Dr. Emershad) informed me they were now aware I was expected to lose the whole 10%. By that time I was already on my way to gaining back the 18 lbs. I had lost during the six months. Their excuse was that all of the other insurance companies were satisfied if you lost ABOUT 10%, but that MY insurance company was very strict about it because I work for the State of Arizona, and this is one of their stipulations. Tish said it wasn't THEIR fault they didn't know about the 10% until I had completed my six month diet. I feel a little differently about that and hold them responsible. My $500 for the six month medically supervised diet, along with all of the out of pocket expenses for the many tests I've had done to fullfill Scottsdale Bariatric's criteria has gone up in smoke, along with my hope for surgery. Now they wanted me to start all over again and lost the whole 10%, and I just can't do it. I feel like I've been HAD! If I have to start over again, that means I'll have to do the psychiatric exam (out of pocket $$$) and other tests all over again too, because we'll be into another year and all of the records will be old. This is just WRONG! After my phone call with Tish ended, I just sat down and cried and cried. I just feel whipped. I guess the State would rather foot the bill for all of my sleep apnea, arthritis, and future weight related problems until I retire. I guess it's back to Weigh****chers or whatever is the diet du jour. Sadly, Pam Evans

Pam, Don't give up. I'm also a state employee and had to fight Cigna when they were the only option that the state had for insurance. When I was fighting for approval, the doctor's office didn't file any of my appeals, I had to hadle everything except the first request myself. You have a couple of options. Start with getting a copy of your benefits book from Schaller-Anderson. Make sure that it was in writing as of October 1st that you had to lose the 10%. If that wasn't in writing at that point, you don't have to comply with anything that went into effect after that. Cigna changed the criteria at least twice during my appeal process and legally I didn't have to comply with any of their changes. 1. You can take your intial denial letter and answer their denial point by point, unemotionally and with verification that you have done everything that was part of their criteria at the time that coverage started. Here are some tips for handling it yourself: Do's and Don'ts of Appeal Letter Writing ________________________________________ DO indicate the reason the claim was denied should be refuted, with the original denial wording used quoted in your appeal letter. DO specifically link all medical studies to the patients individual situation. DO highlight Medical records submitted in your appeal as to doctor treating (name), dates, diagnosis, treatment, etc. DON'T beg your insurance company to approve surgery. When you show weakness, they want to go in for the kill. There's nothing more wonderful than the smell of fear or pity to make some burned out insurance company rat get excited. Rather, write a good factual appeal letter, pointing out where they erred in their decision. Support your facts with good documentation from your attending physicians. (Your medical records.) Keep it as objective and non-emotional as possible. all personal, subjective statements should be removed. The denial will be overturned on the merits, not sympathy. DON'T ever take anything the insurance company says over the phone as accurate. Demand that all correspondence be in writing. Get a copy of your policy, since they may quote a policy provision that isn't even in your policy. THIS IS CRITICAL. I can't overstate this enough. DON'T fax an appeal, or any added documentation. Rather, send it certified, return receipt requested, or overnight so that you have proof of receipt. ALWAYS send a copy of your appeal (in the same manner) to the Vice President of Group Medical Claims. Be sure you indicate on your appeal that copies were sent to the VP, the Insurance Commissioner in your state, (unless it's an ERISA plan which isn't governed by state law.), and all of your physicians. DO use good grammar and spelling. Have a trusted (intelligent) friend proof read and edit for you. You don't want your typos or poor grammar to distract from your intention to sway them to your way of seeing things. If you are not a good writer, consider having a friend, consultant or attorney write the letter for you. THIS IS YOUR LIFE! DO request that the appeal be reviewed by an outside, 3rd party physician reviewer if the appeal is not overturned internally. If you are on an ERISA plan, you have the right to appeal within 60 days of the denial. The clock is ALWAYS ticking. DO request the names and credentials of the insurance representative *****viewed your records, and copies of the specific records that were reviewed. Also request copies of any "expert medical opinions" secured by the company in making it's decision. ALWAYS keep a detailed log of when you called the insurance company, the date and time, the first and last name of the person you spoke with, the questions you asked and the answers you were given. This is imperative! 2. You can hire an attorney to do this for you. 3. I know of a woman who is a paralegal and used to work for insurance companies. She charges less than an attorney and has a wonderful track record. Even if that 10% rule was in place on October 1st, I'm sure there must be a way to get around it since no other companies require it, it flies in the face of what the NIH says and if you could have lost the weight you would have. For me to get approved through Cigna took a year, an attorney, three appeals and the state insurance board, but I did it. It was long and hard, but very worth it. Let me know if I can help. Connie

Wow. Happy girl, This is the best summary of appeal process I've ever seen. I'm gonna cut and paste it into a file on my hard drive in case anybody else needs it. Very well put together primer! Pam, DON'T QUIT!!!! This is your life you're fighting for and you need to have the gumption to know you're standing up not only for yourself, but for those who come after you as well. You need to get back on a diet - which, as you've said yourself in previous posts, you've done so many times over the years. You're one of the lucky ones. You have insurance that will cover if you just jump through enough hoops. You wouldn't believe how many women are out there working for companies that refuse to cover this surgery at all. Don't wimp out just because you've come up on another hurdle. Show them that they're not gonna push you aside and do what it takes to get what you need! You can do it! Good luck. - Stephanie J

Hi Pam ~ When I started this process, my PCP said that if I had any trouble getting my insurance to approve RNY that I should contact Obestitylaw.com. He says that they have helped several of his patients to get approval. If I had not been approved, I would have followed his advice. Don't give up. Valerie in Scottsdale

sorry your having such a hard time. It took almost 2 yrs for me to get surgery I found I had to do most of the work, getting documents together. I went clear back to 1985 I had all my old address books and sent letters to all dr's and hospitals for my records most where free a few I had to pay at most 20.00. In the reports had alot of info on my weight even chiropractor visits. Might try and get another Dr too or talk to another dr office. keep trying I know sounds so hopless but take a break and get ready to fight even if you have to get a lawyer. if you want it bad it will happen. wishing you all the best

Pam, I think Connie said it all,well actually all the posters tell the truth,DONT GIVE UP!!!!! Thats what they want. If you CAN look into seeing a lawyer. I had to fight this for 3 years and I didnt think that it'll ever happen,and I'm the type that gives up.But I knew that this surgery was for me and I did it. Please dont let them get to you FIGHT BACK. Who are they to make you give up,they dont know you,so please stay with it,if this is what you really want then just do it. You can.I will be praying for you. God open the doors for me and he will you no matter what they tell you. xoxoxo Rosie

Okay, Pam.....do NOT stop now!! Please!!! You need appeal this!! I was denied at first too but got approved immediately on the appeal!! Do not give up!!! You are not alone!! We've been there!! Appeal, appeal, appeal!! I did my own appeal. You can do your own appeal too!! Here are some GREAT websites for appeals: http://www.obesityhelp.com/morbidobesity/m-instrouble.phtml www.obesitylaw.com mygastricbypass.com (no www in front of it just the http) www.geocities.com/Heartland/Woods/4485/appeal.html www.gastricbypassfamily.com/Insurance.html (scroll to bottom) www.gastricbypassfamily.com/LMN.html Please, please, please do not give up!!! We are rooting for you 100%! If we can do anything to help, please let us know! Most of us have been denied the first time - insurance companies do that a lot these days. Appeal! Fight for your right to have WLS!! You can do this! YOU are worth it!! Okay, so they say you had to lose 10%, well state that you had lost 18 lbs of the 25 but could not do it on your own - if you could you would not need surgery. Tell them how having WLS will save your life. Tell them that this is just the tool you need to lose the 10% and more to be healthy and live a long life span. You can do this!!! Let us help!! Don't give up!! Hugs, Trisha

Hello I had to put my 2 cents in (for what it's worth). I did not find Tish to be of very much help in my appeal process. My PCP did most of the work in help getting me approved. When I called for pointers all I usually got was don't be emotional. Well I am here saying my last letter was all emotional and as a result Cigna granted me a conferance call with myself and my PCP. They called me back in a matter of hours to say I had been approved. My suggestion is that if you feel like you have covered every base call the insurance company yourself over and over until you get someone who can give you exact information like your policy was changed and on what date. I started this whole process about 16 mos ago and I just had surgery 5-19. I know my insurance is no longer accepting WLS but because I started so long ago I was able to get in under the wire. I was also like you and had given up when my PCP said to write one more letter and give it one more try. I am very happy I listened.

I have to agree with Wendy - Tish was *not* very helpful. In fact, if I'd listened to her, I wouldn't have my approval right now. Once I have had my surgery in July and the bill has been paid by insurance, I plan on letting SBC know exactly what I think of the "help" I received from Tish. She is right that the state is very strict about the 10% - BUT - you don't have to lose it within the 6 months!!! Please look at the very bottom of my profile and read the guidelines there. I am a state employee and even though I have United HealthCare, the guidelines are the same. The guidelines were developed when Cigna had the contract. I didn't lose the 10% within the 6 months. It took me at least another month of unhealthy dieting to do it. I also went and got a body wrap done at a day spa to help me drop a couple of extra pounds. Another possibility to consider - did your PCP refer you to SBC? If your weight at the referral visit at your PCP's office was higher, you can use that weight to help with the 10%. I lost 7 pounds between referral and first appointment with Dr. Emershad, and though they tried to deny me for not losing the 10%, I fought them and got approved. Please don't give up. I would also fight Tish on not knowing about the 10% - they knew about it because she told me about it last fall. Call Carol, the office manager, and talk to her. Please email me if you want to talk. Gabrielle

Pamela; Don't give up. The insurance companies are trying to find ways not to pay for the surgeries. It sounds like Tish wants to give up. Don't let her. Have you asked for help with an appeal letter from the main message board. Maybe they know a trick or 2. I never had problems with my insurance but I did have problems with different programs. Maybe you need to check out other surgeons. The office staff should know how to get this approved. I started my process 2.5 years ago with the Bariatric treatments center on Scottsdale. The insurance would only pay 70%. That was not an option for me. I then started process with the mayo clinic, I did so many test and diets. I was going for almost a year. I never once even saw the surgeon. I was so fed up that, I finally called my insurance and got a list of surgeons that did the surgery. I found the Dr. at St. Lukes. I went in August 2004 for my first appointment and my surgery was in November 2004. I guess my point is if you really want the surgery then fight for it. I know how fustrating it can get and the stress is far more then needed but from the other side now. It was worth it. We are here for you, hope this helps or at least gives you an idea. Good luck, Cynthia