Question:
Anyone dealt with PacifiCare HMO Colorado

Hi, I just got back from my PCP, went to get the referal for the surgery, he gave it to me, but then said he doubted that they would approve it, based on his experience. I've been reading on some boards that they (PacifiCare) have been great to deal with, but his comment today has got me bummed out. I am 28,5'4, 333lbs, and my BMI is 57. I don't have any major co-morbities, but i have a strong family history of heart disease and obesity resulting in early death, before 55. Any comments you can give would be greatly appreciated, you can e-mail me at [email protected], Thanks!!!    — Carey N. (posted on May 16, 2001)

May 16, 2001
hi carey....im from chicago so im not familar with your hmo but i've recently been through the same experience with my pcp who not only didn't give me a referal but continually told me that i wouldn't be approved....all i can suggest you do is contact your insurance company to find out what guidelines they follow in terms of approving someone for this surgery..i.e. co-morbesities or just being morbidly obese .....they will gladly give you a rundown of what you have guidlines you have to fall under. after my disasterous meeting with my pcp. i immediately contacted my insurance company and was pleased to know that i would be covered...so now that pcp of mine is an ex-pcp and im getting a new pcp...and hopefully should be starting the whole process soon....so don't give up hope carey just because a doctor says your insurance won't cover something doesn't mean its written in stone...check it out yourself....good luck to you...deirdre
   — DEIRDRE D.

May 16, 2001
I have PacifiCare of California HMO. It covers WLS in full if you meet the NIH guidelines. Your BMI does meet them, so you'd just need to show that you tried and failed everything else and are psychologically stable enough to understand and comply with the post-surgical (ie lifetime) regimen. My BMI was "only" 38, but they covered my surgery without any problem because of my co-morbs. Best of luck (and don't forget to get a new PCP).
   — Linda B.

May 17, 2001
Carey - I have PacifiCare HMO in California. I'm still in the process of final approval; however.... My PCP told me the same thing - after she told me she didn't believe in the surgery and that I would gain all my weight back after two years !!! Anyway, they did deny my basic referral. And then I sent a big 'ole appeal letter and was approved to proceed. Had my consults on Monday and am waiting for letter of medical necessity... As one of my friends told me (herself a post-op), this is MY surgery and I'm going to do the footwork to make sure it happens. If I had listened to my PCP, I wouldn't have gotten this far!!! Good luck to you. Bobbi Lee
   — blee01