Running on Empty!!

HI everyone, My name is Tamara. I haven't posted hear before. I have been in a year and a half battle with insurance companies to get approval for the Lap Band. First I got shot down by Providence, Oregon even though I had Walter Lindstrom and my Surgeon/PCP backing me up....that took 8 months and external review wouldn't touch it. Now I have been attemtping to gain approval through Legacy Good Samaritan/ODS. They cover the procedure if you have a BMI > 40 and one of their specified co-morbidities. I, unfortunately yet fortunately can't seem to convince them that I do meet their criteria. I have a BMI of 47 but ONLY have Borderline Hypertension....they want moderate to severe hypertension. I have lower lumbar joint arthrosis which is keeping me from exercising and working at times....they want a severe degenerative joint disorder. For some reason, it seemed easier when Providence just denied me because it was excluded under their policy. Being so close to meeting my employers criteria and still not qualifying is really difficult. I feel like I am yo-yo dieting again....a glimmer of hope followed by consistent failure. It really urks me because I work for the Hospital that runs the Barriatric Clinic. What we all know about Morbid Obesity and what has been scientifically documented by the National Institutes of Health, the American Obesity Association, the American Society of Barriatric Surgeons and others, is that Morbid Obesity and it's co-morbidities do not get better without treatment, and life-style changes. I can't lose this weight on my own so I don't know what they expect me to do....work another two years and go on Disability for back/foot problems, or maybe depression and anxiety!!!!! I am only 29 years old!!!! I have been very depressed lately. It seems like things are moving so slowly. I am waiting on my Surgeon to request a review right now. We both think it will be denied. Then I can appeal, and you can bet that Walter and Kelley Lindstrom are still going to be working with me on this. I need them now more than ever. The tough thing is that my hospital is self insured so I am not covered under ERISA law and the Social Security Administration doesn't qualify Obesity as a disability either so I don't think I can claim discrimination. The bottom line is I cannot afford to self pay..not even if I go out of the country and I can't get financing either due to a bankruptcy. I can't even sell my house to pay for it. I feel like I am grasping at straws! I feel like everyone can hear and see me asking for help, and they know I need it, but nobody is listening. My patience is dwindling, but I can't give up.....That's what the insurance company wants. Sorry for such a long post. I don't have anyone to talk to about this and I guess I just needed to get it out of me. I will post again at some point. Thanks to whoever reads this. Tamara

Hi Tamara. I certainly don't have any words of wisdom, but I wanted you to know that I hear you. You are not alone. There are a lot of caring people who are at this site. We may not know each other, but we feel your pain anyway. I will keep you in my prayers, Tamara, and I hope you will continue to post here. Maybe someone else has gone through what you are going through with your insurance and can offer some advice. In the meantime, hang in there. I care. Peg

Peg, I wanted to say thank you for your email! I usually don't unload like that in a post but I really needed to blow off some steam and it helps to hear from others who are going down or have been down similar paths. As for you not having any words of wisdom.....I think the wisest words you can say to anyone at anytime are "I hear you" and "I care". Thanks so much. I will post with more info as I get it. Tamara

Tamara, So you are trying to get approval through the obesity institute? I am a patient of Jay Jan's. I am battling my own insurance company as well. In my own pre-op class there was a nurse from labor and delivery who works for good samaritan, I know when Emma Patterson approached Legacy with all of this she told them that it also had to be a benefit for the employees that is why the nurse was there it was not covered before, and she told me her approval took one day. I went to my pre-op class on 08/24/05 it has been recent from my understanding of the change. DON"T GIVE UP!!! It will come with time....

Molly, Thanks for listening. Your email gives me hope. I trust Dr. Patterson with my life.....obviously! I want to ask her for more help, like calling the Medical Director at the Insurance Company or something like that but I have this dumb problem. I don't want people to see me as high maintenance so I don't always ask for what I need. It really isn't my goal to drive Dr. Patterson nuts. I should just ask but the truth is I don't know what she has done, in my favor, or what she is prepared to do with this appeal....I am afraid to ask too!! I have heard from many others that she is a wonderful advocate and I am sure that she will do more than I could ask to help me out. I am feeling a bit better today. Again thank you for listening and for you response. I will keep you all posted with any progress. Tamara

Hi Tamara. It's Peg again. I just read your email to Molly about not wanting to appear high maintenance by asking Dr. Patterson for what you need with your insurance problems. I think that's pretty typical for those of us with eating problems. We don't tell people what we need, and then we get frustrated and eat. At least, that was my pattern, and I'm working on it. How does that saying go? "Ask and ye shall receive." People can't read our minds. We truly need to tell people how we feel and what we need. I hope you give Dr. Patterson a chance to help. In the meantime, I just noticed that you also live in Beaverton! We're neighbors! Take care, and good luck with your insurance. Peg

Hey Tamara.....I live close to Beaverton and I am also going through the obesity institute at Legacy. Are you sure that it won't be covered? I currently work at the VA hospital and was applying for jobs at Legacy, I asked the MA at the obesity institute and she said that the insurance at Legacy would cover it for sure, is there only one medical insurance available? I would talk to Dr. Patterson or the scheduling people, being that you are an employee they might go out of their way to help you. I know I always do what I can to help employee's at my hospital if I can. Just be extra nice (I'm sure you are) and I'm sure you will get this covered. A good friend of mine works at Legacy and his surgery has been approved. Just don't give up, I'm sure you will be approved soon. I had to switch insurance companies just to get one that would cover this surgery.