First Choice Health (Providence EPO)

My preop testing was completed a week ago, and my surgeon's office was prompt in faxing the information to the insurance company. Every stipulation for approval was met:BMI over 40, nutrition consult with 30 day record, psych consult, documentation of comorbidities (HTN, sleep apnea with CPAP) The insurance does not have an exclusion policy, yet they denied my initial attempt at approval secondary to my BP being controlled on 300mg of Avapro. The reviewer commented that I was only on ONE medication for BP...hey, how many pills does someone with HTN need to take before it is considered a comorbidity??? How about the fact that I have been on antihypertensives for 20yrs !! This feels like a business maneuver rather than a complete denial...or maybe I am in denial! I have read many posts regarding the process for approval, and this doesn't seem to be out of the norm. I imagine some folks will accept the first denial, and then either self pay or give up...never having been one to take "no" well, I have initiated the followup with insurance to include every detail of my battle with obesity...which began shortly after birth! I have contacted my prior PCP to send a letter to the insurance documenting the multiple diets and drugs I have been on for the last 14 years (Phen-Fen etc...) The minute I heard about the refusal, I was immediately hungry! I called my husband, who "talked me down" off the wall and lovingly encouraged me to use my words instead of my stomach to heal the distress. We have been together for almost 20 years and he is awesome... I adore him! We will continue to forge ahead with plans and preparations for WLS and attempt to patiently wait . I have lost 20lbs in the preop phase of this, purchased all the recommended post op necessities and continue to remain hopeful. Thanks for the rant time, any suggestions? Mary

I would hire a lawyer seriously cut all your frustration out. The insurance company will give you a hard time just hire Gary Viscio he really knows what he's doing if you want to save time I would hire him. Not that much money considering they could make you self pay good luck. I used gary got denied in May appealed on my own first got denied again hired Gary in Mid June I did pay a little extra to have my case done quickly but got my deniel overturned by the state July 18th thanks to Gary's help.

Thanks for your post, you are absolutely right, no time to play "insurance games"...I'll look into this tomorrow after I hear from the surgeon's office regarding the first letter post denial. MaryG

BMI over 40 should not require comorbidities. Typical rules are BMI over 35 with comorbidities or just BMI over 40. The fact that you also have sleep apnea should be good enough with BMI over 40 especially. Save the attorney cost for now and write a well thought out appeal. If that still fails, then find an attorney if you can afford one. If not, keep appealing. Jim Randall

Thanks Jim. I appreciate your experience and patience. I will work on the appeal letter while I wait for the insurance decision. My surgeon has made a phone call to the MD reviewer to get some clarity on the situation. The reviewer stated the petition would be re-evaluated, but while I wait, I'll put my time to good use by drafting the appeal. I am passionate about this lifestyle change and have promised myself to make the best use this situation. Thanks again for your supportMary

Mary just to let you know in case you have not looked into this but there is a time limit that you can put appeals in. Meaning if this is your first appeal to the insurance company you might get two from them but remember if they uphold up the approval and I think it's 45 days that past well in my state (ny) then you can't do a state appeal. Just be careful the insurance company will sthal and take all the time they want you have to be on top of them. I used to call a few times a day seriously that's how bad mine was. I hope u have way better luck with process then me but look into there appeal process from the insurance company to the state hope this helps you!

Thanks Jamie...I appreciate your post! I will call the insurance company tomorrow to followup. They spoke with my surgeon once after the first denial, and said they were in the process of "reviewing" the authorization again. I will find out the law for WA state, and plan on placing the insurance review team on speed dial! 45days is not much time...thanks for the heads upMary

Mary, I have First Choice (PPO) Providence Health Systems.  I called them to see if they cover WLS and they do and do a 50K cap.  Do you know of anyone who uses the PPO plan