I fought Healthy Roads and lived to tell the tale...

For those of you with PacifiCare, continue to fight this six-month program. I did, and I won. I believe that I just made myself such a pain in their ass, between my 3 doctors and my lawyers, that they approved my surgery just to get rid of me. I now am getting together my $5500 aftercare "copay" since PacifiCare deems it "medically unnecessary;" once they receive that, I'll have my surgery date. YAY! Things I Have Learned: -Don't take "NO" for an answer -Be persistent. Make yourself a pain in the ass. Don't let them scare you off. -Don't give up; if the low level handler doesn't give you an answer you like, work your way up. -Enroll anyway in Healthy Roads, to show compliance, even while you fight it. -Consider hiring legal representation -Once you have a lawyer, make sure you don't leave anything out...too much paper is better than not enough. I believe between MY papers, my letters from the insurance company, my doctor's correspondence, and the papers the lawyers generated came to about 100 pages.  This does not include the massive amount of emailing that occurred. -If you are in California, you have the best chance of winning an appeal; the DMHC interprets the policy liberally in your favor and strictly/narrowly in the favor of the insurer. -Keep on top of people; get the answers you want. I had to bug my doctor's staff to get my records to my lawyer. Once I did, they had the records within 24 hours. -Have hope; it's the only thing that got me through. You might get discouraged, but don't give up. Now, instead of waiting until at least April 2008, I will have my VSG surgery within the next two months, before the year is out, just like I intended when I started this fight.  I hope this helps the rest of you!

Way to go Meg!!! So, details.... were you denied or did you start the "fight" first??  I am playing the healthy roads game right now   3 weeks into it.  Is that the stupidest thing ever??  I already have my surgeon, done ALL the tests, have clearance from my PCP for surgery....  I dont want to play the game for 6 months!!!

So, do I have my surgeon submit my request and wait and see    or talk to a lawyer now and then submit with the lawyer behind me??

I got two denials before I resorted to legal action. One was a denial based on not having finished healthy roads. The second was a denial for an expedited appeal. Apparently organ failure doesn't count as a "serious medical issue." Coulda fooled me. Have the surgeon submit the request; you have to be denied as far as I know, before the lawyer can do anything.

So, from the time the lawyer joined in, how long did it take to get the yes??  How far into healthy roads are you??      Anyway - Im glad to hear you are getting what you need.

I was four weeks into healthy roads when I got my approval. From first consult to approval, it was about 14 weeks of fighting; 5 weeks with the lawyer involved.

Hi there -  Congrats to you!!! I have a question though - what is Healthy Roads? thx

Healthy Roads is an EEEEVIL Program of manipulation and control.... Ok, seriously, it's a diet and exercise and counseling program, which is done all over the phone; your nutritionist has you set goals like "Drink a v8 every day to get more vegetables" or "park further away and walk into the store"...whatever, to increase your nutrition and activity.  It's basically a way for the insurance company to force you to complete one more six month diet before they'll approve you, even if you have a complete diet history.  In California, the law does not require a patient to show a six month diet history; only a history of failed attempts.  4 weeks in and I hadn't learned a damn thing I didn't already know.