DENIED

Well both of the insurances that I have denied me for the surgery. My company and my husbands company that we work for does not cover the surgery. The Barix Clinic here in Columbus is throwing in the towel. Told me not to bother having any of the tests done. One of the things that made me want to go there was the fact that they fought for you. They are giving in to easy as far as I am concerned. $25,000 up front if you want to pay out of your own pocket. I was so looking forward to this. Well this is not over till this OBESE LADY SINGS!!!!!! Any suggestions, please advise. Thanks.....Julie

Oh Julie, I am so sorry you were denied, you must feel very discouraged. Insurance companies don't want to give in to paying for this surgery easily whether you need it or not. It is a shame BTC wouldn't try harder to fight for you. What was the basis for your denials? How does your insurance policy read regarding weight loss surgery? Do you have any co-morbidities? It may be something simple has just been overlooked. If your insurance has an appeals process, use it. When you appeal make sure you include co-morbidities, their causal relationships to your obesity and deteriorating health, and the diagnostic codes for each. Also detail why this is affecting your health and how it would be improved by having weight loss surgery. Please wait to have tests done unless you feel the results could benefit your case. If there is a chance you have sleep apnea and haven't been tested yet (I can't remember if you said you had or not) do so. This was a major factor in me winning my approval. Don't give up girl! Fight fight fight! And in the mean time, hang in there. I'll be keeping you in my prayers. If you need another pep talk, e-mail me! Hugs, Jaimee

The basis for the denial was that they do not cover it even if medically necessary. My copy of my benefits only mentions that weight loss programs are not covered. Says nothing about surgery. I am a type 2 diabetic. I have not even had any of the other tests to see if I have sleep apnea or heart problems. They basically told me to not have the tests cause the insurance will not cover it. I will take your advice and everyone elses and use it towards my advantage. Thank you for being there... Julie

Who is your other insurer? Your profile talks about UHC and I'm assuming they're your primary but who is your secondary? Get a copy of your policy (the detailed booklet that explains, in detail, what procedures are included/excluded) - your HR department should either be able to provide it to you or tell you who to call to get it. Depending on who your employer is, some policy manuals can be found on-line. Once you get that information, you'll be able to see where you stand. Have you received a written denial? If so, what were the reasons given as the cause of the denial? If it was based on no coverage for obesity, you might be able to appeal based on being morbidly obese if you have proof of medical necessity from your PCP or other healthcare professionals. Do you have any documented diets to show that you have not succeeded at "normal" weight loss measures? If not, get to your PCP and start one. Do you have any co-morbidities? If so, get them documented by your PCP as well as the treatments for those co-morbidities. Copies of medical records showing the diagnosis' as well as your weights as dr. appt.'s can help. They will show how long you've been obese/morbidly obese. I went to Barix (BTC then) and honestly, I did a lot of the leg work myself instead of counting on them to do it all for me. They do the insurance stuff out of the Michigan office and they're doing it for all of the Barix locations throughout the US. I'm sure they have thousands upon thousands of people that they're trying to obtain approval for and it would be easy for a single individual to either get lost in the shuffle or put aside in order to concentrate on those who haven't been denied. I gathered all of my medical records from my PCP/OB-GYN/Urgent Care/etc. on my own as well as records from the dietician that I met with a few times (to meet Aetna's requirements) and I mailed/faxed them to AETNA myself. Unfortunately, Barix submitted my request for coverage to AETNA before I had met all the requirements and needless to say, I was initially denied. Once I finished my required 6 month, dr. supervised diet (Weigh****chers supervised by my PCP), I re-sent everything with my appeal straight to AETNA and sent copies to BTC so they could see what I sent. I was approved within a week. O.K....I've rambled enough.... Good Luck.

My other insurance is Cigna. I guess they are not in network with Cigna, but even if they were, they still do not cover WLS. I do have a copy of my benefits on line. It does not state that it does or does not cover WLS it states it does not cover WL programs. No written denial... verbal denial from Barix Center here in Columbus. I have not had any of the other tests done (sleep tes, ekg and pysch evaluation) I am still going to have my primary doctor schedule these for me so I have them completed and have my proof if needed. I was upset to find that they submitted everything prior to me having any of the tests done. That did not make any sense to me. I will take your advise and see what happens. Thank you again for your support. Julie

Julie, DON'T give up! Contact one of the obesity lawyers and talk with them. I don't have either one of the insurances you do but had an exclusion which required 2 full years of documented weight loss attempts vs. the typical 6 months that everyone else had. Barix tossed in the towel with me citing they knew I'd be denied. Well, yes but I needed to be so I could appeal but they refused to even submit! Told me it would take a legal battle beyond comprehension to get approved. Imagine their surprise when I returned their phone call (just so happened they called to check my status the next day) the day after I got my approval letter. I didn't even have to hire one of the lawyers-did it on my own! So much for their legal battle! Told them ALL they had to do was submit and let clients go from there. I also know for a fact that they hired one of the obesity lawyers to fight for another gal's approval-and he won. Why won't they do that for you? Makes no sense to me! NEVER SAY NEVER! Beth

The other replies gave you great ideas. I just had one other thought. Your employer could be of help. They determine what is covered in your plan. If they change the plan to include WLS it would be covered. I have UHC and my plan did cover it. Best of luck to you. Keep us informed.

I have found the Barix Clinic to be way less than helpful. I had an origional denial letter sent to me because the stuff that my PCP sent to them was sent to the wrong fax number. Then they couldn't find my file for awhile. Also when I called Tabitha from the insurance, she told the people that answered the phone that she had already talked to me and was not going to talk to me again until we heard from my insurance co. I had only talked to her two times in about a months time. I felt this was very rude. I heard someone say that she got it approved herself. How did you do it?