PacifiCare thru San Diego County Employer

Hello, is there anyone out there that work for the County of San Diego that has Pacificare that has been approved for WLS? Here's the dilemma and it keeps coming up for me:

First I tried to get VSG got denied by the Managed Care department at UCSD saying it's not a covered benefit. Called and appealed with pacificare. Says WLS is a covered benefit but VSG is not "see surgeon to review other covered WLS." Ok so I seek RNY find out my surgeon does not do RNY and wants to give me Lap Band (he really doesn't think WLS is a covered benefit) but I don't want Lap Band. So seek help from Pacific Bariatric. Well I have a PCP at UCSD and he referred me for RNY it was denied today saying "WLS is not a covered benefit."

So now the hospital is saying the problem is with PacifiCare saying it's not a covered benefit, and then they want to give me the speak that sometimes insurance with different employers will approve the surgery. Well I stated that there are people with Pacificare that works for the County of San Diego that have been approved thru PacifiCare for WLS and maybe it's how you all are submitting the paperwork. Then she says we usually get Lap Band approved and I said I don't want Lap Band:

I was denied the request to seek RNY thru Pacific Bariatric because it is saying it's not a medical necessity. I am not understanding why this confusion is coming up because they are suggestion that this is something I am requesting not something that I need. Pacific Bariatric says that I need something from my PCP saying that this surgery is a medical necessity for me. I do not want the lap band because the revision rate is to high and there are more negative complications and failure rates with surgery than with the other weight loss surgeries. I have been dieting since I was 3 years old and I still have not been successful and this whole process is becoming quite discouraging. I can't give up because I know that it is something that has to be done in order for me to become healthy. I have tried the "normal tactics" and they have not worked. Please advise.
 

I chose my plan because the other plan (Kaiser) people were having even more problems with being approved! My open enrollment don't begin until October/November and it won't go into effect until January 1st. I guess I better head back to Jenny Craig because I don't think I can wait that long.

Thanks for the heads up but I think Kaiser San Diego sucks and that's why I didn't select them. Although I work local Government we only have a chose of two carriers, Pacificare and Kaiser and I chose Pacificare because I like my PCP, although Kaiser is a lot cheaper than what I am paying for Pacificare. I have been doing Medifast, Weigh****cher, Jenny Craig, etc Ali pills, Green Tea Diet pills, colon cleaning, etc for the last 13 years and it's documented in my charts already. The other weekend I thought I was having a freakin heart attack at 29 so now I think 6 weeks is too damn long to wait. My co morbidities are Hypertension, Asthma, super obese, and anemia. I don't have diabetes yet......was trying to have this sugery before I get all that because it's in my family and I have had it during my pregnancies. I am almost ready to give up but in the mean time I am going to go back to Jenny Craig because I have to get this weight off of me ASAP and that's why I resigned to surgery as my last resort.......

Quick question did your pcp write a letter of medical neccesity? there are some sample letters of what all the letter should state send me a personal message and i will send you the website info. I don't know if my surgeon would want me to just be posting it.. But I figure if it can help you get an approval I say share and share alike... I can also cut and paste the sample letters and email them to you either way is fine for me.. we have the same comorbidities but i also have sleep apnea just found out today.. For everything there is a reason and for every reason there is a season.. Believe that this is your season!!!


Tenisha