Denied...Health Partners MN

So after 14 long days of waiting, on the last day they told me denied because my co morbids are controled with meds. I am 5ft 2in and 215lbs (39,9 BMI) I have Diabetes II, High Blood Preasure, High Cholesterol as my big three and I take 2000mg a day Metformin, 8mg Avandia and 10mg Byetta twice a day. I take 14 different medications a day in all. I am right on the border for everything but we really thought those coupled with hypothyroid, female "issues" and joint issues that have been consistant for the last 5 yrs, I would be approved. as of 9/30/08 the ins has paid $25,000 for my medical. Any suggestions for plan of attack? I may be controled per say but only cause we keep upping doses....HELP!!

So sorry for your denial...I was denied this week, too--after waiting 14 days.  I know how you feel.  I do have some suggestions, though.  First, has your surgn. requested a peer-to-peer review?  Does your insurance company approve w/out comorbids if your BMI is 40?  2000mg/day of Met is really high....but, after a while Met will result in poorly controlled PCOS (I am assuming you have PCOS, insulin resistance, etc.)....my PCP was clear that all my comorbids are poorly controlled with meds.  And, do you have osteoarthritis? 

So sorry for you too. It sounds to me like an approval is right around the corner for you!! Thats my downfall as long as their are higher doses and different meds, and you have to have a documented BMI over 40 for 2 years so that won't work. So if they deny me i will gain 10 and start the clock. My appeals letter is pretty good and they are rushing it into the meeting on Monday. Keep your fingers crossed for me!! Are you appealing?

I would gain 2 pounds and make your bmi 40! then appeal.

Wi**** were that easy but it has to be over 40 for 2 years documented....grrrr

What! Thats crazy! I just got approved and then they told me it was pre existing and told me I couldn't have it till june! I know how you feel! Ive been waiting forever for this surgery! I geuss for some of us we just have to work a trillion times harder :(

So are you for sure good to go for June?? I would even take that if i knew I could get it. They resubmitted me for an appeal today so I should know in a few days...Prexisting Condition?? You have got to be @!#!##@ me!! Of course it is...It has to be to qualify!! Do ya want 2 yrs documented or not!!....lol

well not for sure!!! I have to re do everything!!! But I will fight for it!

 With a BMI over 35 and comorbidities your insurance can not deny you for WLS. If they don't have an exclusion they then they have to cover WLS for you. They do not make it easy but you need to not give up and appeal.  My insurance is trying to deny be for the DS because they say that with a BMI < 50 it is not medically necessary for me.  Just because it's part of their medical policy does't mean it's not flawed. If Medicare and other insurance companies will cover  WLS  with BMI> 35 with comorbidities then your insurance should have to as well. Have you looked into getting the DS (duodenal switch)? It has a 98 % cure rate for type 2 diabetes and you have a wonderful DS surgeon right in your backyard, Dr. Buchwald. Check out the DS forum, make sure you research all your options before setting on any one type of  WLS. Best of luck. PS how retarded for them to deny you because your comorbids are controlled with meds. If they weren't you'd have a heart attack or stroke and die. They just want you to give up and go away.


This is an excerpt from Centers for Medicare & Medicaid Services website: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160   Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity (CAG-00250R)   Decisions Summary   The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is adequate to conclude that open and laparoscopic Roux-en-Y gastric bypass (Gastric Bypass), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic  biliopancreatic diversion with duodenal switch (BPD/DS), are reasonable and necessary for Medicare beneficiaries who have a body-mass index (BMI) > 35, have at least one co-morbidity related to obesity


In 1998 the  NIH a report called The Evidence Report: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.  The 1998 NIH report can be found here in PDF format: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf. The NIH only criteria for WLS is BMI > 35 with comorbidities and BMI > 40 without.