WHY?

butterjoy
on 7/31/08 7:04 am - Elkview, WV

I GOT A LETTER FROM MY INSURANCE. I WAS DENIED. IT SAYS THEY DENIED MY REQUEST BECAUSE: BASED UPON CLINICAL INFORMATION RECEIVED, MEDICAL NECESSITY HAS NOT BEEN ESTABLISHED ACCORDING TO PEIA CRITERIA.

I DON'T UNDERSTAND WHY THEY SAY IT WAS NOT "MEDICAL NECESSITY" WHEN ALL THEY HAVE TO DO IS READ ALL MY FILES. CAN SOMEONE EXPLAIN?

THANKS
JOY

* Our family is a circle of love and strength. With every birth and every union, the circle grows. Every joy shared adds more love. Every obstacle faced together makes the circle stronger. The love of a family is life's greatest blessing.
I have reached my goal!

Eileen Briesch
on 7/31/08 7:34 am - Evansville, IN

RNY on 06/29/04

Because insurance companies figure you won't fight the denial, so they won't have to pay. So prove them wrong and fight back. A lot of insurance companies do this figuring most patients will just roll over and not have the surgery or pay for it themselves. So then they don't have to pay for it. So file a claim against them and show it is medically necessary. Get letters from doctors showing how you need this or you will have serious health issues (or worse health issues than you have now).

This really chafes my butt when they do this. A drug addict doesn't need to prove medical necessity to get help; an alcoholic doesn't need to prove medical necessity to get help; a smoker doesn't need to prove anything either. But the obese have to prove it's medically necessary for them to have this surgery, that they will have worse health issues. We have a woman here at work that is bigger than I was when I had my surgery, yet she has been turned down twice by her insurance (she has a different carrier than I have). She gave up. That's what the insurer wants you to do. They would rather pay your claims for complications from high blood pressure, diabetes, arthritis, etc., than pay for life-saving surgery. It's so stupid.

Well, down off my soapbox. But you should contest this denial if you want this surgery. It's not an easy fight. But if you really want the surgery, do it.

Eileen Briesch

lap rny 6-29-04

[email protected]

butterjoy
on 7/31/08 7:43 am - Elkview, WV

RNY on 11/03/08

HOW? I HAVE NEVER DONE THIS. DOES THE GASTRIC BYPASS SURGEON DO IT FOR ME OR DO I HAVE TO GET A LAWYER OR WHAT?

* Our family is a circle of love and strength. With every birth and every union, the circle grows. Every joy shared adds more love. Every obstacle faced together makes the circle stronger. The love of a family is life's greatest blessing.
I have reached my goal!

phfauche
on 7/31/08 8:05 am - Columbus, OH

REALIZE Band on 04/15/08

Start by talking with your doctor's insurance person and ask her what you have to do to appeal this. The insurance company should have given you copies of your insurance requirements with the section that was not met checked off. I hope you understand what I'm trying to tell you. When I got my 1st denial I got a copy of my requirements with the section hilighted pertaining to the reason I was denied. Oh, almost forgot. On the lap band forum there is a lady named Vicki, she is an insurance person (calls herself the "insurance guru". You could talk to her. She may be able to help you.

Good Luck,

Hugs, Peggy

Darlene
on 7/31/08 9:22 am

RNY on 08/26/00

Sometimes the appeal process is part of the insurance companies process. I know lots of them deny the first try out, then an appeal by the patient is done and mostly then is won. Good Luck.

Women are angels.
...and when someone breaks our wings, we simply continue to fly...on a broomstick.

We are flexible.

Darlene

butterjoy
on 7/31/08 10:16 am - Elkview, WV

RNY on 11/03/08

I AM SITTING HERE TRYING HARD NOT TO CRY. IT IS WONDERFUL TO READ ENCOURAGING WORDS. I WILL GO TO THE OFFICE TOMORROW TO SEE WHAT I CAN DO. I FIGURE THEY WILL MAKE AN APPOINTMENT FOR ME TO SEE THE LADY THAT HANDLES THE REQUESTS. I WILL LET YOU KNOW WHAT I FIND OUT. THANK YOU SO MUCH FOR BEING HERE AND LISTENING TO ME.

ALWAYS,
JOY

* Our family is a circle of love and strength. With every birth and every union, the circle grows. Every joy shared adds more love. Every obstacle faced together makes the circle stronger. The love of a family is life's greatest blessing.
I have reached my goal!

Brenda R.
on 7/31/08 11:18 am - Portage, IN

RNY on 10/08/07

Joy, I am a firm believer in the saying "If God brings you to it, He brings you through it". He has brought you through this far and I don't think He is going to up and leave you now. I will continue to keep you and this whole situation in my prayers. Please keep us posted on how you are doing. Don't give up hope, just keep your chin up and your boxing gloves on!

It's not what you gather, but what you scatter
that tells what kind of life you have lived.

butterjoy
on 7/31/08 9:18 pm - Elkview, WV

RNY on 11/03/08

THANK YOU SO MUCH BRENDA. I KNOW THERE IS ALWAYS A REASON FOR THINGS NOT TO GO THE WAY WE WANT IT. IT IS JUST HARD MENTALLY AND EMOTIONALLY TO UNDERSTAND WHY IT HAPPENED.

JOY

* Our family is a circle of love and strength. With every birth and every union, the circle grows. Every joy shared adds more love. Every obstacle faced together makes the circle stronger. The love of a family is life's greatest blessing.
I have reached my goal!

butterjoy
on 7/31/08 9:26 pm - Elkview, WV

RNY on 11/03/08

I WANT TO THANK EVERYONE FOR HELPING ME. I COULD NOT SLEEP LAST NIGHT. MY MIND WAS GOING IN CIRCLES TRYING TO FIGURE OUT WHAT TO DO. I WILL MAKE A APPOINTMENT WITH THE BARIATRIC SURGEON'S OFFICE. AS SOON AS I FIND OUT WHAT THEY SAY, I WILL LET YOU KNOW.

THANKS,
JOY

* Our family is a circle of love and strength. With every birth and every union, the circle grows. Every joy shared adds more love. Every obstacle faced together makes the circle stronger. The love of a family is life's greatest blessing.
I have reached my goal!

Eileen Briesch
on 8/1/08 2:07 am - Evansville, IN

RNY on 06/29/04

Hang in there, Joy, don't let them beat you down. That's what they want you to do. They want you to accept the denial and go on. If you appeal, you may be surprised at what happens. It's another hoop they want you to jump through.

Eileen Briesch

lap rny 6-29-04

[email protected]

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