Question:
I was denied surgery by ins,

I was contacted by phone by the nurse case manager this morning that I was denied. She said my co-morbidities according to the nurse was not what the ins considers life threatening. She was very nice and sympathetic to me. I have several dx; Diabetes, Hypertension, Arthritis, and Gastritis to name a few. I am scheduled for a sleep study my surgeon suspects I have sleep apnea. Anyone have that considered as a life threatening condition? There is no weight loss exclusion in my policy it just states "No treatment for obesity will be covered unless it is life threatening"- Thanks for all/any responses. Kristee    — Kristee (posted on March 1, 2002)


March 1, 2002
Sound to me that you have life threatening comorbidities. Have your PCP write a letter stating that your diabetes and hypertension combined with your weight are a life treatening condition. If that doesn't work, I would recommend hiring Walter Lindstrom. I dealt with insurance problems for 5=6 months. I have a bmi of 63, severe sleep apnea, hypertension, high cholesterol & triglycerides, back, knee and ankle pain, GERD, etc. All in all I have 6 of the 7 comorbidities that the NIH says only one qualifies WLS as medically necessary, and my insurance denied me. Policy says that it does cover WLS if it is considered medically necessary. After 5 months of denials and runaround, I hired Walter Lindstrom (www.obesitylaw.com) and he filed my level 2 appeal. Within 3 days of the insurance company recieving it, they had approved me Best $350 I have ever spent). Surgery is on Mar 4. Best of luck, and keep in there. Don't give up.
   — Dell H.

March 1, 2002
Sleep apnea is a life-threatening problem. It can cause heart attacks, for one. If you are diagnosed with it, that should be added in your appeal.
   — garw

March 1, 2002
Get that sleep apnea test, and also...why do they not consider Diabetes and Hypertension as being life threatening. My aunt died of Diabetes after she went blind and could no longer walk. Hypertension can cause strokes. I think you should definitely appeal. I don't know who these supposed professionals think they are!!! I think they are quacks!!!GOOD LUCK TO YOU...STAND ON YOUR FAITH
   — Michelle H.

March 1, 2002
Get a copy of "Weight Loss Sugery: Understanding and Overcoming Morbid Obesity." It has excellent advice on how to deal with denials. It's by Michelle Boasten.
   — Mariee H.

March 1, 2002
Hi Kristie... Absolutely APPEAL this denial. I just completed most of 6 months of attempting to get all of this through and went through 3 submissions and denials before having it approved on Monday. You definitely have comorbidities and NIH lists several of yours as comorbidities. Email me if you decide to go ahead and I'll give you some info on things to include in your appeal. Andrea
   — AJC750

March 2, 2002
This would be the way your insurance tries to get out of paying for something they know should be covered. I'm just starting too (haven't even put in a claim to the insurance yet)but I know from past experiences that insurance companies will do whatever it takes to get out of paying. I've dealt with them when it comes to my litte girl, who is a special needs child and requires extra care. Appeal as many times as it takes. If you have to....threaten them by getting a lawyer involved. They act tough, but if you show them you will stop at nothing usually they give in. Good luck to you!!!
   — Lori S.

March 2, 2002
Kristee my insurance company has done the same thing to me. I have all the same health problems you do and more and they are denying my surgery. I have Health Net, I think they are the worse. My surgery was scheduled for Feb. 25th and Feb.22nd they denied it. Talking about playing with your mind!! The insurance broker is trying to intercede for me, if that does not work I am hiring the attorney. I do need this surgery in order to live a healthy long life. Keep trying do not give up!!!
   — Luisa H.

March 2, 2002
Kristee this sounds so familiar to me, I just went thru the same thing last week,my insurance company is Health Net and they denied my surgery 3 days before I was scheduled. It is so frustating to know you have all these health issues and they don't care. Do not give up, Do not give up. The insurance broker is trying to help me with the surgery and if they do not approve it I will get an attorney. I need this surgery to have a healthy long life and without the surgery it is not going to happen. Good luck to you and me too. Luisa Hopper
   — Luisa H.

March 2, 2002
Kristee this is all so familiar to me, I just went thru the same thing with Health Net my insurance company, I was scheduled for surgery on the 25th of february and the 22nd they denied my surgery, you can imagine how sad and frustrated I am. My husband had scheduled his vacation for that week and now everything is canceled. Do not give up, I am not giving up even if I have to get an attorney I am having this surgery to save my life. I have most of the same health issues you have. SO, NEVER GIVE UP!!! Luisa Hopper
   — Luisa H.

March 2, 2002
Kristee this is all so familiar to me, I just went thru the same thing with Health Net my insurance company, I was scheduled for surgery on the 25th of february and the 22nd they denied my surgery, you can imagine how sad and frustrated I am. My husband had scheduled his vacation for that week and now everything is canceled. Do not give up, I am not giving up even if I have to get an attorney I am having this surgery to save my life. I have most of the same health issues you have. SO, NEVER GIVE UP!!! Luisa Hopper
   — Luisa H.




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