Question:
HELP ! ANY CALIF PACIFIC CARE HMO MEMBERS?? 2 TIMES DENIED

I need help with my ins. co. Pacific Care HMO...I have just been denied twice in 5 mos..First time they needed a psych eval which I did, and 6 mos dr supervised diet which I did...NOW they say that my dr supervised diet was not documented enough in detail by my PCP.But I had the whole 6 mos....I think that this is just an excuse.....my BMI is 44 and I have several co morbids..(2 pages worth)... I am filing an appeal next week with another letter from my PCP, but I NEED SOME HELP FROM SOMEONE ON WHERE TO TURN NEXT...Has anyone had this problem with Pacific Care?????    — Joi G. (posted on June 19, 2001)

June 19, 2001
Hi Joi, it sounds to me as though they are using delay tactics. If the only reason you were denied the second time is because diet history wasn't detailed, then it sounds as though your chances of approval are very good, IMHO. Just have you PCP submit a more detailed documentation of medically supervised diets attempted. I don't have pacificare, but I do have BCBS PPO and was denied twice also. I recently got my approval after the request for WLS was reviewed a third time. Since you do have a lot of comorbidities, have you gotten other doctors to write on your behalf and recommend surgery? I believe what did it for me was a letter my pulmonologist wrote stating that I need CPAP therapy and supplemental oxygen. If you wish, you could also contact your State Department of Insurance and ask them to intervene or you also have the option of retaining a lawyer. Walter Lindstrom seems to be the one that many WLS members use, his website is www.obesitylaw.com. I really hope you don't have to resort to those measures, you know it's said the third time's a charm :o) I wish you all the best.
   — dandjon

June 20, 2001
I also have pacificare HMO of Oklahoma and they have done the same to me. excuse after excuse the six month Dr. supervised weight loss program and everything. I am lost I dont know what to do. I will go for a member satisfaction hearing next I am scared to death.They have approved people in the past. I have started looking under insurers and asking other people that have been approved with pacificare how they did it. good luck!!
   — Angie H.

June 20, 2001
Hi, I have Pacific Care HMO and was approved in 2 weeks. I had the surgery on Feb. 13th. I prepared a 2 page letter on my history of dieting. Starting at age 5 when I weighted 125#, it was very detailed with age - weight - and things I tried to lose weight -from hypnosis, bariatric bubbles, weight watchers, tops, oa, diet pills,etc. I gave this letter to my pcp, and she sent a letter to Pacific Care. My co-morbidities included insulin diabetic, severe back problems. Good luck.
   — connie m

June 20, 2001
I have pacific care HMO. It took me about 2 weeks to get approved. I gave them a detailed diet history from age 10. My co-morbities included gastric reflux and stress incontanance. I also wrote in detail my strong family history of heart problems and diabetes on both sides and the ages my parents had their 1st heart attacks. Good luck
   — pokergirl59