Anyone with Group Health insurance???

I am a Group Health employee and patient and have been denied twice, surgery is scheduled for June 11th!!!  Does anyone have any suggestions?? I am at my wit's end, the criteria on my plan is if your BMI is 40-49(which mine falls into) you must have one or more of the following co-morbidities: diabetes, high blood pressure, sleep apnea or venous insufficency with stasis ulcer(non-healing). I had the ulcer and incompetant veins and had my veins stripped on both legs, but they are denying me because they healed AFTER surgery??!! I also have a family history of obesity and diabetes, heart disease, and high blood pressure, it is a path I am headed down unless I can get the weight off. I am so frustrated and would appreciate any help and suggestions you can offer.  Sue

Hi Sue,

     I have Group Health.  I was initially denied too.  I think part of the battle is your PCP.  Did you get a referral?  Once I was denied, I went back to my PCP with documentation stating all the adverse things that were happening to me because of my weight.  Then I wrote a letter to the board with the same kind of information about my deteriorating health.  I was approved.  Basically I covered all their possible denials before they had an opportunity to say no twice.  I had very few co-morbidities but was on the edge of them.  My PCP actually fudged a little with some knee arthritis.  I really think being prepared ahead of time is what worked for me.  I might even have a copy of those letters saved on my home computer if you'd like for me to look.  The most important thing is to not give up.      I had surgery on 8-8-06 and have lost 110 lbs.  I have between 15 and 20 left to go.  I feel wonderful.  Are you scheduled with a GH doc in Spokane?  Both of the GH docs in this area are wonderful.  Good luck with your quest.  Let me know if I can help.

Carol

Hi Carol,  My PCP did do the referral initially, he is in agreement with me on having the surgery. It is Group Helath that is saying I don't meet criteria.  I also have knee pain, but the only way to use that is with documented x-rays of arthritis. The worst part is I also am a employee at Group Health!  I don't plan on backing down anytime soon. My surgeon is meeting with the medical director today, so hopefully he can get somewhere!  I would love to see the letters you sent to them, if you still have them. I am willing to have all the help I can get on this!  Thanks for responding and congratulations on you sucess! 

I had Group Health for 29 years and was denied and denied for WLS. I finally got tired of them and switched to Regence Blue Cross / Blue Shield in 01/2007 and had my surgery on 05/24/07. I'm sorry I don't have any advise as to how to actually get an approval. I say switch insurance plans if possible. I am so happy with BC/BS, I will never go back to Group Health.

I am an employee at Group Health, this is my only option. They are a great place to work! I am just frustrated with the approval process.

Hi Sue~ I have GH.. and struggleed with my PCP for ever with WLS..as he felt it was not nessecasry...I changed PCP's and with a bit of pushing, she was willing to submit the referal. I had several tests done and it was found that I have a VERY MILD case of sleep apnea, plus a BMI over 45 and I am happy to say that I have been approved and scheduled for WLS on 8/1. My advise would be try changing doctors, and see if that might not help. Good Luck Collette

Hi Collette,  My PCP is in agreement on the surgery., the problem was I didin't have any of the co-morbidities, my BMI is 46.2. I did however, have a sleep study done last night and I have moderate sleep apnea, so I am hoping that is my ticket.  Thanks for all of you help and info! Good luck to you on your surgery!  Sue

With the sleep apnea diagnosis, you should be approved.  I was denied the first time with my sleep apnea diagnosis but only because the paperwork got sent in without my Dr.'s referral included.  Once I had all my paperwork including a heartfelt letter from me, it took about 30 days to get approved.  Good luck to you!!!

Sue, Don't get discouraged! I have Premera BC and am going through a slightly different hell. My mom went through it with the VA dependent insurance two years ago. I'm sure that GH will eventually approve you, but you may have to write a heart-wrenching appeal letter (like my mom did after she was rejected the third time). I'm surprised that GH requires 40+ BMI *and* co-morbidities. National Institute of Health says 40+ *or* 35+ with co-morbidities.  Also, you may have co-morbidities that qualify but aren't specifically stated in your policy (and they certainly won't *offer* them to you). By NIH guidelines qualifying co-morbidities (in addition to what you listed) are: GERD, Arthritis/DJD, High Cholesterol/High Triglycerides (hyperlipidemia), Insulin Resistance (pre diabetes), High/Low or imbalanced cycles of blood glucose levels (pre-diabetes), nerve compression/neuropathy. Some other things that help are Carpal Tunnel or other repetitive stress injuries that can be linked to or are/will be worse because of your weight. Migraines and chronic headaches, especially if related to back tension because of your weight, can also help. Best of luck! Jennine

Hi there! I'm a Group Health employee as well. I work in Customer Service. When you were denied, did you appeal? (it would have involved sending in a letter, etc) Danielle