Not yet denied but a bunch of hoops

I haven't even met my surgeon, but my PCP sent in the precertification request. Of course, they sent it back saying I need documentation within 45 days. I'm not sure whether to go along, or just give up and self pay. Besides the normal stuff (dietician, psych, surgeon eval), they want proof that within the last 2 years I've had a "physician supervised diet, with integrated exercise, behavior modifications and support," and proof I've tried weight loss drugs in the last 2 years. I have done both of these, and they can be documented, but not within the last 2 years. Should I try to squeeze something in within the 45 day limit? And how do I know if it will be good enough for them? Can I just call and ask them upfront? Donna C

Hi Donna, It's kind of strange that your PCP sent in a letter of pre-determination. Usually, the surgeon does that to make sure they will be paid. The 45 days you were given to provide documentation to them, is the time period that they will hold the request for prior determination open to allow you time to "perfect" your claim. Do not give up and walk away. You need to fight this with all that you have. Insurance companies know that most people will not appeal a denial. They COUNT on the fact that you will put your tail between your morbidly obese legs and slink away into a corner. My mother taught me that anything worth having is worth fighting for. Send them all the diet documentation you have with a letter summarizing all of your failed attempts. Reiterate to them that you meet the NHLBI consensus statement guidelines, which just require a history of failed diets. No time frames or length of failed diets are articulated in the consensus statement. Fight the good fight! Roberta

HIjack~~ Roberta, What is the NHLBI consensus guidelines? Possibly, something to do with Donna's insurance, but it could be something very helpful that I can include also. Thank you, once again!! Laryssa

Sorry about the Hijack... Hey Roberta, I understand through other board members you are good in dealing with the quirks of the insurance industry and am hoping you can point me in the right direction. Right now I am the same boat... not yet officially denied, but would be if the request for authorization had completely gone through. I have BC/BS (HMSA) Federal Employees Program. Lap-Banding is covered by regular BC/BS (or HMSA) but not for those under the Federal Employees Program version. As of 13 Jan 04, "Adjustable gastric banding (CPT code 43843), whi*****ludes the Lap-Band procedure, is no longer considered investigational. However, the procedure is not covered by FEP as it is not a benefit of that plan." They DO, however, cover various types of Gastric Bypass under both policy guidelines. I spoke with a nurse case worker today *****lated I fit the criteria for WLS (unfortunately). What I am looking for is help in getting around this. If I meet requirements for WLS, AND they cover WLS in general, I feel as though I should be afforded the opportunity of choice. Thanks for any and all help. Candy

Listen, if you could, go to this website and see if this pertains to your situation http://www.jawadmd.com/. Actually, this is an excerpt of what I'm sending you to read. I just noticed you said you have BC/BS so I just wanted to warn you. That website above is where I found the info. That website is for my bariatric surgeon, Dr. Jawad. ********* As you may already know Blue Cross Blue Shield has decided to exclude the Gastric Bypass Surgery on all there policies starting January 1, 2 0 05. What you might not know is that they will not honor any approvals after January 1, 2005. This means that if you have not had the surgery prior to this date, you will no be able to have it or be considered as Self-pay. This decision will not only affect you, it will affect millions who are trying to overcome this life threatening disease. BCBS decision is base on purely prediction on future expenses that will incur due to the overwhelming demand for the surgery. The state Office of Insurance Regulation has approved the exclusion endorsement for large groups and small groups. As Dr. Forrester Vice President of Health Care Services & Chief Medical Director Of BCBS (HOI, Blue Options, Blue Choice) quoted on his final draft dated 1/22/04 " The popularity of Bariatric surgeries has grown dramatically in the wake of well-publicized operations among celebrities. The number of gastric bypass surgeries in the U.S. Has nearly doubled in the past year, and the demand is expected to grow exponentially."

Hey Heidi, Thanks so much for the information. Is this new exclusion for FL BC/BS in particular? I'll be asking my insurance company this very question (if they are going to be excluding it after the first of the year) first thing Monday. CT

I would definitely contact BCBS first thing Monday because it doesn't sound like only Florida. Good Luck!

Donna~~ I am in a very similar situation with my insurance, GHI cbp. Just wanted to let you know that i will keep you in my thoughts and prayers. I do know, how frustrating this is. Laryssa

Laryssa, Thank you for your support. Roberta is right -- I just want to slink away and not even fight it. I even took out a home equity line of credit just in case I have to self pay. I'm particularly worried about the time lost fighting it all when I could be losing weight. I will also keep you in my thoughts and prayers. Donna C

Hey Donna, Ditto, to Laryssa's posting!! I just can't understand how an insurance company can cover one type (albeit a broad type) of WLS and not another. Best of luck to you and will keep you in my thoughts and prayers as well. CT