Insurance rejection help

This is a long one, but please help if you can. I am hoping someone out there can help me with this problem. I have Great West Healthcare, which covers lap-band surgery if deemed medically necessary. I have met ALL of their requirements, including the morbity obesity weight (100+ overweight), BMI of >40 (mine is 41), 3-4 cormobidities (I have 8), primary care physician recommendation, and a psychiatric evaluation (passed). In addition, my sleep apnea specialist wrote a letter of recommendation for the surgery. All of my doctors, including a spine specialist, have indicated that the 10 medications I take now could be reduced by one-half, including not having to use a CPAP, and that my comorbidities would be reduced to none. The medications alone cost Great West about $2,000 a month and the doctor/specialist visits must be in the thousands per year, so they'd actually be saving money by paying for my surgery. I happen to be bipolar and have seen a psychiatrist for 2 years, who filled out a form indicating his approval of my lap-band surgery (this was separate from the psychiatrist at the WISH Center in Renton who tested and interviewed me for the surgery). Great West has denied coverage for the 2nd time stating that the psychological evaluation does not meet their coverage criteria, that a full psychological multi-axis assessment was not performed. This is crap! I feel I am being discriminated against because I am bipolar. I would have had the extra testing if they had indicated it in the very beginning. I am going to appeal again, and this time I am going to include the filing of a complaint with the Office of Civil Rights that under the American with Disabilities Act, my civil rights are being violated. I am also going to file a complaint with the Washington State Insurance Commissioner's office. Any thoughts on this??? The second reason they denied me is that they did not receive clinical information indicating I had been on a physician-supervised low calorie diet, including nutrition counseling, increased physical activity and behavior modification for a period of 6 months within the past 2 years ago. In 1996, I entered an outpatient program for overeating at the Moore Center in Bellevue Washington run by one of the leading authorities on eating disorders in the state. I saw this doctor and attended group therapy for almost ten years, until May of 2004, when I switched to a doctor whose expertise is in bipolar pharmacology. The WISH Center insurance person told me she had never seen such excellent documentation, and that this is the first time Great West has denied coverage after the 1st appeal. She is stunned. Is there any point in appealing this, or do I have to start over? They also indicated that a program supervised by a physician specializing in bariartric surgery, so the 3 months I've checked in with the dietician, exercise physiologist at the WISH Center is null and void. If I start over with this supervised program with my pcp, what are the ramifications? Of course, I'll lose weight, so does that then mean they will deny me because I lose 10-20 lbs? How do I get around this catch 22? "Cheat" on the supervised program so I don't lose weight? I'm 52 and have been on every diet in the universe since the age of 10, and have always gained back more than I initially lost. Thanks so much for any help!

I'm sorry that they are being so difficult . The people at the wish center should have an idea what the real issues are . Maybe the diet data isn't recent enough . Don't give up . Does the wish center have a human resource person ? If you do have to do another diet , don't cheat . Your adherence to the diet is also an indication as to whether you'd be compliant once you have the surgery . Are you concerned about getting below 40 BMI's ? You can go below that with your comorbidities . Take a deep breath , call the insurance & tell them you want to know specifically what they want . You need it in writing , too . Good luck . Kathy

Hi Chandler. I too had Great West and was denied due to doumentation of a DR. supervised weight loss program. I had started Weigh****chers and had been on it off and on for almost 6 months. All I did was flub a little and fax my WW documents over and they approved me. If you want more info, contact me at [email protected] There are ways to get around this. I don't know much about the bipolar part but I think I'll have some great info for you on the diet part. Good Luck, Tracy F.

Hi! Insurance companies can be a huge pain in the butt. I used to work at a dental practice and know all about dealing with them. Unfortunately insurance companies do not work for the patient or the doctors, they are only concerned with making money and that doesn't include paying out on expensive procedures like this even if they are suppose to. Here's my best advice. DO NOT GIVE UP. Ins companies depend on people giving up after a denial or two so they don't have to cover the expensive procedures and most of the time it works. Absolutely tell them you are issuing complaints to the WA state insurance commision and the other one you mentioned as well. That tends to get their attention and we used it often in our practice with good results. I would also get on the phone and try to get the highest up person you can in the company. Customer service reps and even their supervisors often can do nothing but if you keep after them you should be able to reach someone high enough up that can give you real answers and who will take your threat of complaints to federal and state offices seriously. The biggest thing is to stay calm, don't yell or get mad even if you want to because they'll just hang up if you do, just keep asking for that person's supervisor until you get one that seems to know what the heck they are talking about and can do something for you. You'll probably have to explain your situation many times but with some patience and perserverance you should wear them down. I hope this helps a little and good luck!! Corinna Q

Many, many thanks for this very helpful information. I'm going to be on Great West like the poverbial stink on--well, you know what I'm saying. I'll let the message board here know when I've succeeded. Best of luck to you!

Chandler, I too have Great West. I am wondering if the issue here is that you are having the Lap Band rahter than the Bypass. I have a co-worker who was denied for the same reasons you were (and I was too). She actually had to take it to an independent review board after 3 formal denials. I will be honest with you.. when dealing with them she was very nasty to them and I understand the frustration. She refused to do the 6 months of medically supervised weight loss. Only after having her case heard by an independent bariatric surgeon (sort of like arbitration) was she approved. I, on the other hand, was denied initially. When I read the fine print it indicated they had not received ppwk that I KNEW I had taken care of, (The psych eval) and also due to the lack of 6 months regulated diet program. I Dr Lauters office re-fax the info they were missing. And Upon seeing my friends struggle with Great West I did a few things differently. I started going to my PCP every month under the appt type diet/excercise due to morbid obesity. They weighed me and I would show them a food diary I kept. I will be honest with you, I never lost any weight doing this. If the insurance wants documentation I was going to document them up the wazzoo!! In my appeal letter I focused on my health issues and how loosing this weight was going to SAVE THEM MONEY! (I actually used the sample appeal letter on the OH website as a template) Also, upon my first denial I was given a nurse case manager. He actually was VERY helpful to me and I really believed he was fighting for me. I communicated with him every day. I had his direct number, and if I had to leave a message he always got back to me the same day. Within 2 days of filing my appeal I called Robert (nurse case manager) and within 2 hours he called me back with my approval. Just a couple of things... I would stay calm and as hard as it is, try not to get ugly with the insurance. You can guarantee they have all thier ducks in a row. Threatening them won't help you I'm afraid. Remember the goal is to get them to work WITH you on this. FIND OUT WHO YOUR NURSE MANAGER IS AND GET THIER INFO. THEN BE A PEST... altho a NICE PEST. THat person will be instrumental in helping you get approved. ) This will happen!!

Great advice Rebecca . You get more bees with honey than vinegar . Kathy