Re: Approved with PPO/insurance?

[Guest guest]

I just got approved by BCBS of land this week. They had initially denied

me due to exclusion from contract. I pulled out my employee's benefits guide

and went through it tooth and nail. It seemed the manual did in fact state

weight loss surgery was not covered, EXCEPT in the instance where a BCBS rep

deemed the surgery medically necessary. Then I went to my employer's

Benefits Administrator. She was a HUGE help. She was an intricate part

because she had the all mighty " contacts " inside the hell known as the

insurance company. I used that to it's fullest potential. I put together a

notebook. The first page being my letter. In my letter I referenced with

Appendices all my backup documentation. My first Appendix was the denial

letter from them. My second Appendix was a copy of the page reading that wls

wasn't truly an EXCLUSION but rather had to be deemed medically necessary by

them. Then my letter turned to my medical necessity. I included a 14 year

diet history with back up documentation that included photo copies of check

registers from 1987 that showed my payments to Nutri-System, TOPS,

Physicians Weight Loss Clinics, Weight Watchers, etc. I cited that over the

course of these 14 years of dieting, I had somehow managed to gain 88lbs. I

was at a disadvantage (if you want to call it that) that I really have no

true medical complications. I'm not sure why, but by the grace of God, I

have not had any sleep apnea, no high blood pressure, no diabetes, etc. No

typical obesity type ailments, but I knew they were coming. I pointed out my

obese grandmother had died from a stroke when she was 62 due to high blood

pressure and obesity. My mother was now taking high blood pressure medicine

and my sister was also obese. I had back up documentation from Dr. R.'s site

showing how NIH, the Mayo Clinic, the New England Journal of Medicine and

other respected professionals in the medical field felt that with a BMI of

50 I was an ideal candidate for this surgery. I took this huge mound of

material to my Benefits Administrator and she got it to one of her people

who got it through the chain of command. My battle started in February 1999

and on May 12 I learned from my Benefits Administrator that I was approved.

Oh, another factor I thought was crucial in this denial being overturned was

that I cited some other cases I learned about through this list and the

OSSG-NY-Metro list where BCBS of MD had approved the surgery. I hope this

helps someone in their fight with the insurance battle.

A friend from land,

Janet

age: 35

bmi: 50

status: pre-op Just Approved by BCBS of MD on 5/12/99; surgery date 7/19/99

family: married 15 years with 4 children (2 girls & 2 boys)

[Guest guest]

Thanks Kathy. If my letter can be helpful to one person, I will be very very

happy. I can't even begin to tell you how many stories here have been

helpful! Especially the other Kathy! She's a true beacon for all!!

A friend from land,

Janet

age: 35

bmi: 50

status: pre-op Just Approved by BCBS of MD on 5/12/99; surgery date 7/19/99

family: married 15 years with 4 children (2 girls & 2 boys)

[Guest guest]

Thanks Kathy. If my letter can be helpful to one person, I will be very very

happy. I can't even begin to tell you how many stories here have been

helpful! Especially the other Kathy! She's a true beacon for all!!

A friend from land,

Janet

age: 35

bmi: 50

status: pre-op Just Approved by BCBS of MD on 5/12/99; surgery date 7/19/99

family: married 15 years with 4 children (2 girls & 2 boys)

[Guest guest]

Thanks Kathy. If my letter can be helpful to one person, I will be very very

happy. I can't even begin to tell you how many stories here have been

helpful! Especially the other Kathy! She's a true beacon for all!!

A friend from land,

Janet

age: 35

bmi: 50

status: pre-op Just Approved by BCBS of MD on 5/12/99; surgery date 7/19/99

family: married 15 years with 4 children (2 girls & 2 boys)