I Need Help...PLEASEEEEE

Hello All, I have been down this road before about 3 years ago when I first decided to have WLS.  Back then I was thinking of getting the gastric bypass but was truly afraid of the surgery.  I did all the test and everything and when I got denied I basically used it as a sign that it was not meant to be.  Here I am three years later and an additional 30 pounds heavier ( I am 5'6 and 315 lbs and 37 years old), and have made up my mind to have the lap-band done because it is what I feel most comfortable with.   Iwork for Verizon and have Healthnet for insurance.  They do cover the surgery and I went on the website to look at my policy and what it entails.  I found a surgeon that I am happy with (Dr. Nussbaum, the ones in the past seemed all to eager to slice me open) and went and had a consult.   His surgery coordinator gave me a list of what I would need through my insurance whi*****luded: Psyche Consult Nutritional Consult Letter from the Bariatric Surgeon Letter from PCP Proof of a 6 month Doctor supervised diet This is what I found also in the policy.  Prior to this I had already started the Doctor supervised diet and taking Phenterime to help.  The problem is that I did not realize that I needed consecutive visits to the PCP for weigh in so I went June, July, October, November and have an appointment for December. I got the psyche and nutional consults, the letter from the Bariatric Surgeon, The letter from my PCP, Cardiologist, and Orthopedic Surgeon as supporting documents.  I have been obese more than half of my 37 years and have had Healthnet Insurance for the past 7 years. I have chronic joint pain, lower back pain, shoulder pain, disc degeneration, arthritis, stress incontinenence, a fatty liver, chronic cystitis, insomnia, generalized anxiety disorder,  reflux and my cholestrol is borderline but I do not have high blood pressure, diabetes and the sleep apnea has not been tested. The coordinator submitted the information and Healthnet DENIED me!   Now they need in addition to everything submitted the 6 month of supervised weight loss even though in the past 7 years I have been on other supervised diets.  I figured I can go through March and get the 6 month consecutive. Plus they want a 5 year weight, height, and BMI history.  What is up with this?  I called Helathnet and a case manager is supposed to call me back and I am still waiting.  I sent them an email and I am still waiting.  I am teerting on calling and losing my temper badly.  I understand the requirements but when they tell me that they need proof that I have been fat it annoys me because every claim they have paid the first code written in is always the code for obesity. Any advice on what can be done?  I would appreciate any help I can get.  I am not willing to take this as a sign anymore because I can't afford to wait another 3 years and 30 pounds more.  I need this surgery to be able to live long enough to care for my daughter who has her own health issues and I'm all she has.   I am studying currently in University of Phoenix to get my degree in Health Administration because of all that I know needs to change in health care.  This battle goes way back and I am ready to fight it to the end. Thanks for reading my rants and raving, Feedback welcomed :) Norma

Hi Norma, Your insurance company really isn't asking for anything unusual.  The six month supervised diet is becoming more and more the norm.  And just about everyone's profile that I have read has insurance that required the five year weight history.  That proof is usually also required by the surgeon's office also.  I know that it can seem like we have to jump through hoops, but most insurance companies approve after getting everything on their requirement list.  For them to pay out that kind of money to cover the surgery is worth a few extra months of dieting.  Look at it this way -- it will give you more time to get your body in better shape for what it will be going through.  Hang in there.

"Plus they want a 5 year weight, height, and BMI history.  What is up with this?  I called Helathnet and a case manager is supposed to call me back and I am still waiting.  I sent them an email and I am still waiting.  I am teerting on calling and losing my temper badly.  I understand the requirements but when they tell me that they need proof that I have been fat it annoys me because every claim they have paid the first code written in is always the code for obesity." Don't get mad.  Get even.  Get all your medical records together and submit them with a well written appeal.  While you're doing that, go through their requirements and make sure you either did or will meet them.  This way, if your appeal fails, and it depends on the plan, though Verizon is normally self funded, which means no State review, then you'll have the documentation to re-submitt. Also, don't rely on emails or phone calls.  You need to insist on something in writing.  Pin them down or they'll keep changing their reasons.

Norma, I too work for Verizon (Wireless).  I have insurance through Verizon (Cigna) and was approved the first time i submitted the request. All insurance companies seem to ask for the 6 months of dieting.  Try to look for any documentation that you have that shows height and weight for the months that you are missing.   The key is the 6 months of continous dieting history.  The insurance company called my doctors office because they were missing 1 month of documents but after it was faxed i received the approval the same day. Work on those months...and your approval will come....I just know it will. Good Luck