Need help with getting a referral BS HMO

I'm having some trouble obtaining my referall to go to the weight loss surgery center that my Dr. is trying to refer me to.  I'm hoping for some advice or information that would help me.  I went to a seminar on my own, not by my Dr.'s suggestion.  I have Blue Shield HMO and my medical group is Memorial Care IPA.  At my request, my Dr. (who has had gastric bypass herself) submitted a request for a referral for me and told me it would take approximately a week to receive an answer.  It has been over a month and after many phone calls on my part to my Dr.'s office referral department and my medical groups referral department, I've been told that it's not a "medical necessity" and that it's "elective".  I have over 225 lbs. to lose, my bmi is 59/60. I'm 36 years old, have been on medication for high blood pressure/cholesterol, edema and acid reflux for 15 years so this baffles me.  I don't have diabetes or sleep apnea so maybe this is why?  They haven't denied me a referral but are requesting "6 months of documented failed physician supervised diets".  I do not have any such documentation and do not want to wait for 6 months to then be told what I did or tried isn't sufficient or whatever other excuse they may have.   I have also been attending the support groups for the surgery center, attended nutrition classes for gastric bypass and have had a psychiatric evaluation (I was trying to get these done while waiting for my referral).  My Dr. submitted written information on what diets and attempts to lose weight that I have told her I've tried (weigh****chers numerous times, exercise and carlorie diets) but I have no proof so it's just her/my word.  We're still waiting for an answer.  If you have any advice or information on if this sounds like standard procedure or how to get around this or anything.......  I would appreciate it so much.  I would hope that my bmi and existing high bp and cholesterol would be enough.  If there is a sample letter for appealing a referral denial please direct me where to find it.  Thank you very much for your time and help in advance!   Sincerely, Lisa M.
 

 Did your medical group ever send you a written denial? They need to send you something in writing stating that you are denied so that you can appeal. Even if they didn't send you anything you need to call your insurance and file a grievance against your medical group for not giving you an answer to your PCP's referral in a timely manner.

With your BMI over 40 you do not need any comorbidities. But you do have comorbidities  high blood pressure/ cholesterol, edema and acid reflux are all comorbids. Do you have a copy of your insurance's criteria for WLS? 

Do you live in CA? Let me know and I will help you as much as I can. BTW have you looked at getting the DS (duodenal switch) with your BMI the DS would help you lose more of your excess weight and keep it off. 

Thank you for the reply .  I called my medical group yesterday and they said that the referral was denied and they recommend a 6 mo. physician supervised program.  They are sending a letter in the mail.  I called Blue Shield today to file an appeal/grievance.  The rep. said there are 3 ways to do it.  Over phone, online and through mail.  I am doing all 3.  I asked what their criteria is for bariatric surgery and she said she'd send me the info in the mail also.  That's the latest.  I do live in Southern CA near Long Beach.  I've been in contact with O.C. Memorials center for obesity throughout all of this.  They're just waiting for my referral.  Where are you located?  I haven't decided which surgery as I figure my insurance or the surgeon will dictate which one I should have.  I know I don't want lapband.  Thanks again!
Lisa

I'm sorry to hear about the runaround they're giving you.  Have you thought of switching to another doctor?  Since your current health condition "automatically" qualifies you for weightloss surgery, I would think that all you have to do is go to a new doctor and have them give you a referral.

Good luck and let us know what happens.

~Linda

Hi, thank you for the reply.  Well, it's not my Dr. I don't think, it's my medical group that's denying me the referral to the surgeon.  I put in an appeal with my insurance co. so I'm just waiting.  Thank you for the wishes.

:)
Lisa

Hi, Lisa!  I think I misunderstood you.  By "medical group" you mean insurance company?  I thought you meant a group medical practice.  Either way, good luck, hope you win your appeal.

~Linda

Hi Linda by medical group I do mean group of Drs.  She's with a group and that group is deying me a referral unless I have done a 6 mo. physician documented diet.  I obviously don't want to wait 6 mo. but I'm afraid that if I switch to another Dr. the same thing will happen.  AGhhhhh.

Lisa