DENIED!

I am soooo right now..I just found out I was denied for insurance because of a wt loss exclusion. What absolutely gets me about this is that my husband and myself called them atleast 3 seperate times to ask them if they had an exclusion for gastric bypass and were told each time by seperate people that they do cover it if medically neccessary and if we meet the requirements so what on earth is this letter all about!!?? Thing is, I have only seen the surgeon ONE time and all we did was talk, he does not have my medical records from my pcp yet or anything else, I am still finishing up the tests he wanted done before second consult so why on earth would they submit any bill to them yet? (besides I paid him $200 cash that day) I do not know why but for a while now I have felt an uneasy feeling in the pit of my stomach about the surgeon..ever since I went to Johnson city for the upper gi and etc. I had called his office and found out he had not done any of the things he had said he would. Not to mention he hadnt even sent the order next door for the appts he knew he required so I was delayed for 45 minutes while they wrote up an order and faxed it over. I want to fight this to the end or die trying but I cant help but want to cry my head off right now.. I am down but not out.. NOT YET anyways.. I only wish I knew where to go now and what to do next! I sure wish I had a lawyer to fight this! Oh well.. life does not give us any garauntees does it. Please say a prayer for me if you would as I sure could use it today.. I am really struggling to stay positive. (but not giving up!) Dawn Knoxville

No Do not give up and if your insurance is anything like mine they denied or refused to pay your OFFICE VISIT not the surgery. If your dr filed it for weight loss then they proball;y wont pay it. My ins has a weight loss exclusion and will not pay for anything other than the surgery. So are you sure they are denying the surgery. If you are seing dr watson. Then i am telling you they will not file your stuff until all of the testing is done.. I know cause i had mt last visit 2 weeks ago and they have still not got it faxed to the insurance yet... They continued to tell me NO WE WILL NOT FILE UNTIL ALL TESTING IS COMPLETE. This is for both drs so i am told. However the booklet does tell you you may even have to pay the 300.00 for the office visit if your plan has an exclusion... So hopefully this is what they are not going to pay..... My insurance did end up paying for my 2 office visits.... Now as for as the dr himself no i did not like having to wait 2 hours to see him nor did i lkie driving 2 hours only to be sent home and rescheduled for the next day. because he had emergemcies at the hospital.. If i have an emergency I waould want him too. WLS surgery is not the only surgery dr watson has done. I have researched himand a couple of others in this area I have friends inh this area who are nurses who work with these drs and i have friends who are drs.... DR.Watson comes very highly recommeneded (spelling) the 2-3 hours i had waiting in this office was very informational to me.. Patients who praised his work . Even people having other surgerys did too... So no i did not think he spent enough time with me i felt rushed for my 200.00 I still am very confident in him.. Now as i sit and write i am remembering that you are seeing Hodge arent you?? Well i know the office procedure is susposed to be the same I was told... my ins does not cover hodge so i chose watson... Anyway dont give up that is why you are having these tests to prove the medical nessassity..... LOts of hus to you Michelle

Ok was i clear? Dont know how i double posted. I was trying to say maybe the insurace is not going to pay for the office visit if it was filed under a weight loss visit.. Did you look at the date of service date? I really bet it is for the office visit... I too paid 200.00 cash for the procesing fee. not the office visit...My insurace did finally pay the 2 visits

Hi Michelle, Hodge refused to do my surgery, turned me over to Watson, and he also refused. I had a negative psych eval, with medical problems. Now I am back to the researching area of finding a Dr. I paid the $200. I delivered all my files, tests, referrals, everything to the office. They are making me now get a notorized copy to release my records and want to charge me to get them. Told them to take it out of the $200 that they didn't earn. Keep trying. If you feel confident with the Dr. keep him, I didn't. I felt rushed, and they would not accept the fact that I didn't have pulmonary hypertension. They took the word of my lung Dr. before the test was done. I am hoping that I can have it done either in Knoxville, or at the Veterans Hospital in Huntinton, WV where I am from. Since I'm a veteran, it won't cost me anything. But the 6 hour trip. Best of luck with your surgery, Michelle. It will happen should it be God's will. Love Kathy

Kathy Hi i think you have gotten a little mixed up *LOL*.. I am going to watson ans hodges in Johnson city..yes but i have not been denied anything( I was replying to Dawn),,, they have been great. I am very comfortable there.. I have heard nothing but wonderful things about them... I would much rather a dr deny to do my surgery tahn them do it knowing i would probally die. or if the surgeon did not feel comfortable doing the surgery i would not want him too do it. I am sure they had to have good reason to not want to do the surgery for you, However i would not give up i would get a 3rd opinion since you already have 2 let someone else look cause both of them are together. So i wish you the best on your journey as well... Michelle

No Do not give up and if your insurance is anything like mine they denied or refused to pay your OFFICE VISIT not the surgery. If your dr filed it for weight loss then they proball;y wont pay it. My ins has a weight loss exclusion and will not pay for anything other than the surgery. So are you sure they are denying the surgery. If you are seing dr watson. Then i am telling you they will not file your stuff until all of the testing is done.. I know cause i had mt last visit 2 weeks ago and they have still not got it faxed to the insurance yet... They continued to tell me NO WE WILL NOT FILE UNTIL ALL TESTING IS COMPLETE. This is for both drs so i am told. However the booklet does tell you you may even have to pay the 300.00 for the office visit if your plan has an exclusion... So hopefully this is what they are not going to pay..... My insurance did end up paying for my 2 office visits.... Now as for as the dr himself no i did not like having to wait 2 hours to see him nor did i lkie driving 2 hours only to be sent home and rescheduled for the next day. because he had emergemcies at the hospital.. If i have an emergency I waould want him too. WLS surgery is not the only surgery dr watson has done. I have researched himand a couple of others in this area I have friends inh this area who are nurses who work with these drs and i have friends who are drs.... DR.Watson comes very highly recommeneded (spelling) the 2-3 hours i had waiting in this office was very informational to me.. Patients who praised his work . Even people having other surgerys did too... So no i did not think he spent enough time with me i felt rushed for my 200.00 I still am very confident in him.. Now as i sit and write i am remembering that you are seeing Hodge arent you?? Well i know the office procedure is susposed to be the same I was told... my ins does not cover hodge so i chose watson... Anyway dont give up that is why you are having these tests to prove the medical nessassity..... LOts of hus to you Michelle

THANK YOU MICHELLE!!! After posting the last message I stepped back a bit and reread the letter about 10 times, reading all of the fine print etc.. they listed at the bottom what page the exclusion was on in my insurance coverage booklet and low and behold there was a sentence they failed to add to the end of thier reason for denial.. and guess what.. They do cover certain procedures if you meet the criteria which I do! This was a sneaky way to try to get me to drop it but they have a big surprise ahead lol... I am not giving up! I read every single page in the book and discovered that with all 5 things they listed as requirements, is as they had previously told us on the phone calls and I no longer worry about the approval..I have it in bold black and white as proof to it. And this booklet just came into effect June 1, 2004! You were very right about the bill being submitted, it was the doctors visit and that is why I was denied. However when all of my testing is completed, and all of my records are put together, we can then schedule second consult and show medical necc. as I meet EVERY single requirement!.. SO I am glad I stepped back and looked at it again because I so worried it was it for me and I panicked.. My health gets worse all of the time and I really Need this surgery! Now my only real concern is with how I will handle Dr Hodges for second consult financially.. if they believe there is an exclusion they may demand payment before he will see me next time.. I sure hope not.. not all at once anyways..Lord Knows I will pay what it takes to get there and get this moving but have always been such a worrier.. dumb huuh! IM TRYING to get better with patience issues but very hard! Thank you for your response, it was a huge help for me! HUGGS, Dawn

p.s do you by chance know what these are in ENGLISH? lol I want to be VERY clear as to which is which for sure because these are the procedures they will cover.. gastroenterstomy..gastric stapling..jejunoileal by-pass..and suction assisted lipectomy Thanks and hugs to you! Dawn

gastroenterstomy..gastric stapling..=The procedure used is called Gastric Bypass Roux-En-Y Gastroenterstomy Jejunoileal Bypass-A surgical procedure consisting of the anastomosis of the proximal part of the jejunum to the distal portion of the ileum, so as to bypass the nutrient-absorptive segment of the small intestine, to treat morbid obesity. suction assisted lipectomy =Liposuction is a surgical technique to remove unwanted fat deposits under the skin from specific areas of the body, including the face and neck, upper arms, trunk, breasts, abdomen, buttocks, hips and thighs, and the knees, calves, and ankles. There are several methods for removal of localized or regional fat deposits, each of which involve placement of fluid (usually dilute local anesthetic solution) into the deposits, followed by the application of suction for removal of the excess fatty deposits. The suction may be applied by use of a vacuum pump (machine) or via closed syringe system. Current clinical experiences and investigations suggest that use of ultrasound (Ultrasonic-assisted Lipoplasty- UAL) to assist in fat removal in fibrous areas has some significant advantages.

Dawn, would your Dr. be Watson or Hodge in Johnson City? Hodge turned by files over to Watson, and both denied me after taking my $200. Says because I received a negative psych eval and had medical problems. DUH, that's why we go to the extreme to have this surgery, is to elimate the medical problems caused by being over weight. Don't give up, Dawn. I'm not. Maybe it's a good thing. Since we haven't been able to get much information on those two Dr.'s, maybe The Lord doesn't want us going thru them. I am checking with Dr. Mark Colquit. He has his seminar this Thursday evening at 6pm at Blunt Memorial. I'll be the one in a red power chair. Hope to meet you there. He dropped his $3000 fee to $500. He only collects that once you have been approved. In the yellow pages of the phone book, go under phycians and call the referral number. They can give you his phone #. Best of luck to you, and KEEP FIGHTING, eventually the right Dr. will be there for you and will be able to get you approved. Trust God on this matter. I do. Love Kathy