Got my Denial

I got my official denial today after 13 months of going back & forth from insurance to caseworker. I was not really surprised or even that disappointed. Well, because I was expecting that answer. I did find out through all the tests I am healthy as a horse and should be thankful for that. Don't get me wrong I didn't want this for my looks. I am 150 lbs. over-weight. I have all the problems of the restaruant booths, airplanes, fun rides. Walking a lot hurts my legs, not to mention my heel spurs. I may do one appeal & the put myself on a diet. I never stick with them long because I have so much to loose. It is time I make the choice to loose before all the problems start. Even if I loose 1/2 the weight I will be so much better off.     This is the safest place I have ever been. My whole life I have felt like hiding. I feel comfortable here & not alone. I have met & talked with a few of you. I feel better with you guys than I do my outside friends & even some family. This is the only place I didn't feel like the only over-weight person or that they didn't know how I feel. I pray EVERY night for every person on this board & will to continue to do so even if I am not on here much more.    As I told Juanita this week-end, I fell 8 weeks ago & messed up my elbow. A lot of weight went on it. lol I will be having surgery at Vanderbilt on the 17th. I will be dealing with this for a good while so I will not do anything about the appeal yet. I was told it is a painful surgery & a lot of thearpy will be in my future.    Anyway in my absense I wish the best to all you who have had or trying to have the surgery. Melinda, Kathy & Kym I hope you & everyone else find answers to your discomfort. Shelia, whatever your problem is I hope it all works out. I have not talked with you but you seem to be the angel on this board in my eyes. Always there for everyone. Susan you seem to know all the answers. I would have turned to you for advice in a heartbeat. April, good luck on that baby. You will be a great mom. Miss Juanita, you have stole my heart. Get that head up. You are such a sweetie. Kathy, take it easy on the hottie next door. Don't over do the walking.   Gosh, this almost sounds like I am leaving. Kinda scarry. I guess I feel if I'm not a loser I should move on. I will probably still lurk to check in on you guys.       Hugs to all,     Ellen

Ellen,  I am so sorry that after all you have been through to get denied. I really hope you change your mind and continue to post. You are family now and I am being really selfish and don't want you to leave. : ) I Still plan on visiting you while you are at Vanderbilt and will continue to be here for you no matter what. I feel like I have gained a few sisters here and I count you as one of them. Keep your head up as well girl and know you are cherished and loved here. Juanita

You are a sweetie. I still want you to come by too. I have your e-mail in my address book. So, happy you are feeling better. I see Dan popped in. My hubby misses his jokes. Hugs Ellen

Did they give you a clear reason for the denial? Sometimes it is a simple piece of paperwork that is missing. Don't give up!! Perhaps take the time while you are rehabing that elbow to start working on your appeal. That will give you something to think about other than physical therapy. Most importantly...don't leave us!! We're here for you. Hope all goes well with the elbow surgery and you have a speedy recovery.

Thanks Susan,     Actually, I haven't got my letter. I got a e-mail from my case-worker at my surgeons office stating she did. She said I will get a letter stating why & how to appeal. She said it said not medically necessary. I have received 2 letters that said that. Then, when she called them something was missing. I think all grounds have been covered with what they need. My surgeons office does not do the appeals. She said I will be on my own. She was no help anyway. I  even had all my surgeons required tests. I had to pay a lot out of pocket. Now, I know I should have only done the insurance requirements. But, as I said earlier I found out I am very healthy just obese. I am going to try & start a diet & use my profile for up-dates. I will be playing around with info for the appeal. My insurance stated if my weight was double the weight it should be and/or my bmi is over 40 I did not need co-morbidities. I fit both those. I was hoping that would work for me. Thanks Ellen

Don't give up! It took me over a year to get approved! Just see what they said you are missing, the reason why. Once mine was the 6 month diet report. Once it was the fact it got sent to the wrong dept. I would advise you to call your insurance when you feel better, and ask to speak to the person who approves the WLS. That's what I did, and kept getting transfered until I got the right person. I asked her what exactly I had to have to get approved. She knew,and read off a list. I checked off the things I had done, and followed up to my pcp to make sure the missing information had been sent. I found the weight loss diet reort of 6 months had somehow been missed. So, I went back to my pcp and asked them to resend it to my WLS dr office. Then, I called that office back, and gave her the number I had been given by the insurance and had her fax it there. I waited one week and followed up on it again. I offered to come by and see what I needed to do next.  At this point, and another call from my wls dr's office, would you believe I got approved? lol I am not sure I made sense typing this, but you get the idea. It is a journey you must follow up with over and over. At least it was for me. Sending you hugs and courage for the upcoming surgery and God's continual strength to carry on with your WLS quest.

Hi Ellen. I am really sorry to hear about your denial. Please do not give up on this. Insurance companies do try to discourage people with denials and think they will just say ok and move on. Do not. Keep fighting for it. I know how hard it is to keep fighting but if you really feel this is the surgery for you and that you want to have it for your future health, then fight for it. You should receive a letter stating why they denied. You mentioned that it was because it was not medically necessary? Did you have a PCP letter stating that it was? Also, I know you mentioned you have a BMI over 40. Do you have a family history of medical issues. If so, have your PCP write another letter and you write a personal letter to the insurance company telling them of the medical problems that you are likely to develop and how medical necessary this is for you  because having a BMI over 40 is medically necessary enough. I really hope you fight this and are able to be sucessful.  I hope you recover quickly from your upcoming surgery. Good luck.

DO NOT GIVE UP!  That is exactly why insurance companies deny.  They want you to get tired, go away, get fired, quit, die, anything that will mean they dont have to pay a claim!  Give em heck!  There are sample appeal letters that people have posted on OH so please take a look around and try to find them.  Do an internet search.  Try to find some that have worked for people.  Sick em and get what is rightfully yours!  Insurance companies  =   anti Christ.  OK Yes Im' a bit extreme but they know that the longer they can postpone payment or approving services, the more money they make off of your employer's money as it gains interest!  Call your HR department.  Threaten them with calling the insurance commissioner, the senator, the governor, heck whoever you have to!

  Thanks for the encouragement Ddee, Misty & Melinda I am ready to fight now. lol Really you girls have me ready to tear into them. I have played around in searching for appeal letters. I will wait for my letter to see what it says. Surely I can peck around the puter with one hand.    Ddee, everything you said is exacly how my whole yr. has been. Finally they didn't lack anything else. My hubby said people at his work say their insurance person is a butt & don't try to make any effort to help anyone.  My pcp did say she felt I needed it. She wrote a really impressive letter. My heel spur doctor said the weight loss would help my spurs a lot.  Thanks for the boost girls, Ellen

LOL. I can see you are feeling better and back to your old self! Yep, you are so right!