Question:
HMO Approval--Medical Group or Insurance Co

I have Blue Cross California Care, an HMO. My PCP will put in the referral letter along with a letter I prepared, but he says my ins will not pay because they regard it as cosmetic. Last time I attempted approval with another HMO (Cigna), it never got past the medical group. Who actually gives the thumbs up for this procedure -- the Med Group or Blue Cross & are there any suggestions as to how I can get beyond the Medical Group--Pathways (formerly Affiliated Private Practice)? I have a BMI of 46 & comorbidities. If anyone works for either of these companies, any suggestions would be appreciated--actually, any suggestions from anyone would be appreciated!! Thank you in advance:)    — [Anonymous] (posted on October 19, 2001)

October 18, 2001
The thing is you must prove is that it is NOT cosmetic, that it is MEDICALLY necessary. Get your information together, medical history w/ comorbities, family history, letters from every doctor you have seen due to your obesity, a strong diet history, and etc. Prove to them you need this surgery. Then if they deny you you have to appeal and try again, don't give up because they say it is cosmetic. If you don't fight for yourself no one will. Good Luck!
   — [Anonymous]

October 19, 2001
I have the same insurance. It is my medical group that has been the problem. They denied me on the gounds that I did not have 6 months of medical weigh loss. If they would have looked in my medical file they would have seen 3 years of medical supervised weight loss and Gain. The insurance company has been great. They have walked me through the process I need for the appeal and once it reaches the appeal it is there choice not the medical groups. I just sent my 106 page appeal via fedex yesterday. E-mail me or check out my profile if you have any questions. Maybe we can work together on this. What is your medical Group?
   — Kathy P.