Help

Does anyone know how I can get this surgery done? I have had 3 appeals, 3 denials. I'm in banckruptcy, and can't afford to pay for the surgery. With diabetes, severe neuropathy, osteo arthritis in my knees, GERD, sleep apnea, edema & asthma, I can't understand why the medcal necessity of this doesn't count for anything. The frustration and depression that settles in is indescribable. Pacifi(doesn't)Care is more like it Any ideas? Jeanne

I dunno thats sucks...when the insurances dont approve. (((HUG))) sorry for the trouble your havin! LISA

Hi Jeannine ~ I am surprised to hear about this with Pacificare. I have Pacificare Signature HMO. And I was approved on the first try. Had my surgery on May 25 and I'm doing great. What doctor office are you dealing with? My surgeon is Dr Fang, and his office staff, especially Angelia, is terrific at getting the right stuff to the right insurance company to get approval. Valerie in Scottsdale

I am so sorry. I know two people personally that got denied here in US and had to go to Tiajuana to have their surgery done and they paid cash for it - so you'd have to save up for it. Dr. Kuri in Tiajuana Mexico. Here's his website - www.beliteweight.com. Also, ObesityHelp has a South-of-the-Border forum - http://www.obesityhelp.com/morbidobesity/south-of-the-border/posts.html So far the two people I know that had Dr. Kuri have had NO complaints and are losing weight and doing good. Sorry that this is happening to you. By your post, I'd approve you! Sounds like this surgery would save your life and extend your life by YEARS!!! Don't give up!! Also, this is a good site - mygastricbypass.com (no www just the http). Hope this helps you!! Hugs, Trisha

Hi Jeanne, I'm Paul from Glendale Arizona. My medical situation was very much like yours. I was denied by Blue Cross Blue Shield of Arizona so I decided to go to MEXICO for the LAP BAND Surgery . It was almost one quarter (1/4) of the price here in Arizona. I went to Dr. Kuri in Tijuana just over the border from San Diego. The health care was wonderful the people treated me like they really wanted to help me. They will also finance the surgery if needed. Check it out if you like, go to the Web Site http://BeLiteWeight.com I am very happy I decided to do this the total cost was under $9000. Paul

I have Pacificare HMO, i have high blood pressure, type II diabetes, and was more than 100 pounds over weight, I was aprroved in just days with no questions and neer had to pay anything, they were great!

Jeanne, The squeeky wheel gets the grease! You appeal again and again! Has "Pacificareless" given you a SPECIFIC reason IN WRITING for the denials? If not, request in writing via certified mail(I know, but you need PROOF it arrived) the SPECIFIC reason(s) why you were denied and give them 5 business days to respond in writing to you. Insurance companies don't like putting anything to specific in writing so don't be surprised if you get vague language. I know, because I fought CIGNA(sickya) HMO for a loved one's heart-lung transplant! The insurance company has time and money on it's side but EVERY rule they make can be broken by the right person(s). Did you know that CIGNA's LEGAL Dept decided my dear one's transplant could happen in AZ after THEY terminated their contract with UMC in Tucson several months prior? HMMMMMMMM !!!!!!! If you need to speak to the insurance company be brief, courteous and specific, ask for things in writing and document WHO you spoke to,date and time as well as what was said. Keep in mind your conversations are ALWAYS recorded for "quality" Ask your HR Dept(if you have one) for the specific language of YOUR employer group's contract with Pacificareless and tell them why. Sometimes when the HR dept of an employer group starts asking the PAcificareless the same ??? s you are things suddenly begin to happen! Worst case scenario if you can't get SPECIFIC reasons for the denial write a letter stating basically what you did in this post stating concisely the dates of your denials and appeals, copies of any letters of Medical necessity you have from docs(or ask for new ones if you need to) as well as ANYTHING relevant to document this process, any correspondence from Pacificareless about your process. Letters asking for more documentation, records etc from Your insurance company show that they were considering your request on some level. Stress in your letter that for you this is A MATTER OF LIFE OR DEATH in your case because any of your comorbidities can kill you more quickly combined with obesity. Include information from the National Health Institute that cites WLS as the only means of losing and KEEPING off weight permanently. Do your homework about WLS and why it works. Solicit the help of the adressees in obtaining approval for your WLS> Once you finish this very effective and persuasive letter showing that WLS is the appropriate solution for you long term you send it as well as any other supporting information(neatly highlighted) to the AZ Medical Director as well as the National Medical Director of Pacificareless, your primary care doc, specialists, bariatric center doc, the head of your HR dept, EVERY national Senator(John McCain's name garners much attention) and national Representative as well as your local district state senators and reps. Make sure these names all appear as cc's somewhere on the letter. Send all copies to any Pacificareless people certified and keep all those receipts! You asked how ....hope my ideas are helpful. It is much work but how worth it will it be? The money I spent for copies, postage as well as the time saved my loved one's life. He was transplanted 2 years ago and is doing great in SPITE of CIGNA! You can do it !!!! Once the letter we sent to everyone went out things happened very quickly. You can do it! Good luck and let us know how it goes! Kathy