Question:
Has anyone EVER been approved for WLS w/ OHP? I was denied.....

I had OHP/Open Card during 2003, my PCP sent a very informative,eloquent and thorough report to the powers that be at OHP asking for pre-authorization for WLS (which he wholeheartedly recommended to me based on my co-morbidities). OHP denied surgery, saying it was not a covered service. However I am very thorough, and I had done my research, I checked OHP's Line Item list of covered treatment/procedures, and WLS surgery IS,indeed,COVERED,- IF it is MEDICALLY NECESSARY AND ACCEPTED TREATMENT FOR THE CO-MORBIDITIES (of the patient)- My BMI-62, weight 330,height 5'3", age 50, hypertension, arthritis and extreme pain in the weight bearing joints, shortness of breath on exertion, major depression (i wonder why ?),anxiety,GERDS,hiatial hernia,back pain,hypoglycemia (borderline diabeties)and Hep C, which my liver specialist won't treat (with interferon recombatant therapy-chemo, basically)until/unless I lose enough weight to bring my BMI under 40- can you believe that? If I were able to just "lose the extra 200 pounds or so", don't you think I would? Guess who's shopping for a new liver doctor! My point is this- OHP would (in my case) prefer to continue to pay for expensive medications and treatments FOR THE REST OF MY LIFE than to SEE THE BIG PICTURE! That's just ridiculous!...My health gets worse with every passing day, for real, and based on family history, my life expectancy is in the low to mid 90's. I don't think I will make it to my next birthday (in July)without the WLS. ... I am sure that I could get Social Security Disability and Housing and Food Stamps and OHP for the rest of my life, but I want to get better. I want my health and MY LIFE back. I am a single parent who's youngest son turned 18 in July 2003,(my oldest is 33)and I want to be around to see my grandkids arrive and my children thrive. WLS isn't just something I WANT, its something I NEED, just as badly as I need the air I breathe! I've always had good jobs, but got laid off and was out of work for over 2 years, Oregon has the highest unemployment rate in the nation,you know. Instead of applying for SSD, I decided to take the first job I was offered that had good health benefits attached. My current job started out at just over minimum wage, which just barely stretches far enough to pay our rent, but not all of our normal monthly bills. We have cut back on everything. No more cable tv, no more fast food, dining out or going to the movies, or trips to the beach. It sucks, but my benefits kicked in 2 weeks ago and I am just waiting to hear that my medical benefits have begun before I start scheduling appts. I selected the EPO option, even tho it was the most expensive way to go, because one of the carriers is United Healthcare, and my EXTENSIVE research online says that the ROUTINELY APPROVE WLS,in fact, I havent seen any feedback saying anyone has been denied by them. I can self refer to specialists, and will have a $250-co-pay with 100%of the rest of the cost of surgery (inpatient OR outpatient) paid by United Healthcare. I will keep you posted on the website message board. Please, people, SHARE WHATEVER INFO & SUPPORT YOU HAVE WITH ALL THE OTHER FOLKS WHO ARE RUNNING INTO THE SAME BRICK WALL YOU ARE-NO ONE NEEDS TO TRAVEL THIS ROAD ALONE. ******* As for Oregon Health Plan, it angers and frustrates me so much to know that I have always been a productive member of society who's paid plenty of taxes to this state and to the federal government, and who, now, I need the help, can't use the benefits that my contributions (taxes)are supposed to be paying for. I PAY TAXES,WHY CANT I GET THE SURGERY I NEED TO SAVE/EXTEND MY LIFE? ...SIGN THE PETITION! We can change this if we all work together, dont let those who come later have to fight the same battle, if things dont change, we all lose.    — debby H. (posted on January 19, 2004)

January 19, 2004
OHP should pay! If there is no exclusion and obviously you've done your homework and found out that they SHOULD cover it, then there should be an appeals process that you can take it to. Did you find out if there is that? I know that for other insurance carriers there is a process in place to appeal decisions like this. I'm interested to know if you took this all the way... ?
   — Julesbird

January 19, 2004
What is OHP? Is it the name of your insurance? I feel for you with the frustrations. Peace and well wishes sending your way!!!!
   — Jencastle

January 19, 2004
Debby, I know several who are in your shoes - who have fought OHP all the way up the ladder - only to be shot down. I'm sorry - the state of Oregon, is, indeed, short sighted! Have you found any of the Oregon WLS Yahoo groups? Here are a couple of links, you will find people here who have been fighting the same fight! http://health.groups.yahoo.com/group/Northwest-OSSG/ http://health.groups.yahoo.com/group/DS-Oregon/ Hope that helps some, and please feel free to email me any time. Blessings, dina
   — Dina McBride

January 19, 2004
My friend was approved for WLS (duoedenal switch) in Oregon. But she was denied first. She then hired Walter Linstrom. He is a lawyer, specializing in overturning denials with an appeal letter. I have also retained him. You can get more info on his website, www.obesitylaw.com If you have any other questions, you can email me at [email protected]
   — Jeanne S.

January 19, 2004
Debbie, I think the key here is to not give up. Some companies are almost always going to deny you the first time. There are alot of people out there who, after the denial, give up. Please appeal, and fight for your rights. I wish you the best. May God Bless You. Janice
   — betterfitness

January 19, 2004
I personally used Gary Viscio as my lawyer. [email protected] good luck.
   — superellen

January 20, 2004
***First off....do you have a surgeon yet? my suggestion would be to get a surgeon lined up and have the surgeon submit ALL the paper work to OHP (including all documentation of co-morbidities and a letter from your pcp). My surgeon required me to see a dietician, sleep specialist, psychologist, pre-op support group meetings, supervised diet, liver specialist (because i have NASH), ekg, and several rounds of blood work as well as a physical and letter from my pcp before i could even make an appt w/her . I have heard that OHP WON'T DO ANY PRIOR AUTHS, but they make their decision AFTER the surgery, crazy (just what i have heard, not a fact)!! I see Emma Patterson at Legacy Good Samaritan in Portland. Their office is great and said if I had a problem with my insurance (not OHP) that they would kind of lead the battle for me (as much as they can). Luckily i didn't have any problems with my ins co. Also, I am in the medical field (LHS) and know that if you have commercial insurance (UHC), that OHP will ALWAYS be secondary, thus they would be billed for your $250.00 co-pay and I'll tell you what, even if they don't pick up the $250.00, that is a small price to pay for your surgery. Most hospitals will MAKE PAYMENT ARRANGEMENTS as long as you make the arrangements PRIOR TO SURGERY. I will end up paying more than that out of pocket after my insurance pays. my ins only pays 90% and my secondary insurance has a specific written exclusion. that leaves me a bill of about $3,000.00. Let me know if you have questions. feel free to email me. It is a matter of hoops to jump through. Hope this helps:>) keri lap rny 12-29-03 252/225
   — Keri P.