Re: Approved with PPO/insurance?

[Guest guest]

Hi my name is Mcintyre and I am a referral nurse with Humana Ins. I

was denied and I have the PPO. I appealed and my appeal was denied. I

challenged the contract with my personal letters and Dr. Rutledge's a[[eal

letter and I was called by the corporate benefits director yesterday and told

that they have already faxed a addendum to the appeals dept. on behalf and

they would be clarifying the exclusion that excludes services for the

treatment of obesity to be worded that is is a covered benefit if you meet

the criteria of morbid or clinically severe obese and the medical

indications. tell your relative to keep fighting and do not give up.

Angie

[Guest guest]

Now since some of you have put all your efforts and energy into ins. battles

would it be un-cool to copy off you. Could you send some of your strongest

arguements and oppositions some of their responses and any battle stratagies

that you have used ,

out on the list to any and all your comrades? the more info the more paperwork

the better. perhaps a few letters from post ops that state the dramatic physical

and emotional improvement that the surgery has done for them in ins. language of

course, decreased meds, improved bp, less dr. visits you get my drift.

occationally when a post is helpful in my situation i copy it and put it in my

file any an all that would be willing to contribute stratagies and battle plans

to all our files would be appreciated

carrie

Pat Eppler wrote:

>

>

> Angie,

>

> My name is Pat Eppler and I have also been denied twice by my PPO insurance

> and I am trying to work up a challenge to the policy. Would you mind

> telling me exactly what you did and send me a copy of your letters if you

> don't mind. I am so discouraged about their attitude. I want this so badly

> and as I am in my 50's I feel that my time is running out for this surgery!

> Thanks for any help you can give me. My email is " eppler@... " .

>

> > Re: Approved with PPO/insurance?

> >

> >

> > From: Amkm784734@...

> >

> > Hi my name is Mcintyre and I am a referral nurse with

> > Humana Ins. I

> > was denied and I have the PPO. I appealed and my appeal was denied. I

> > challenged the contract with my personal letters and Dr.

> > Rutledge's a[[eal

> > letter and I was called by the corporate benefits director

> > yesterday and told

> > that they have already faxed a addendum to the appeals dept. on

> > behalf and

> > they would be clarifying the exclusion that excludes services for the

> > treatment of obesity to be worded that is is a covered benefit if

> > you meet

> > the criteria of morbid or clinically severe obese and the medical

> > indications. tell your relative to keep fighting and do not give up.

> >

> > Angie

> >

> > ------------------------------------------------------------------------

> > Get involved. Share your thoughts!

> > http://www.onelist.com

> > Join the ONElist Weekly Survey. Go to homepage for details.

> > ------------------------------------------------------------------------

> > This message is from the Mini-Gastric Bypass List at Onelist.com

> >

>

> ------------------------------------------------------------------------

> Where do some of the Internet's largest email lists reside?

> http://www.onelist.com

> At ONElist - the most scalable and reliable service on the Internet.

> ------------------------------------------------------------------------

> This message is from the Mini-Gastric Bypass List at Onelist.com

[Guest guest]

Now since some of you have put all your efforts and energy into ins. battles

would it be un-cool to copy off you. Could you send some of your strongest

arguements and oppositions some of their responses and any battle stratagies

that you have used ,

out on the list to any and all your comrades? the more info the more paperwork

the better. perhaps a few letters from post ops that state the dramatic physical

and emotional improvement that the surgery has done for them in ins. language of

course, decreased meds, improved bp, less dr. visits you get my drift.

occationally when a post is helpful in my situation i copy it and put it in my

file any an all that would be willing to contribute stratagies and battle plans

to all our files would be appreciated

carrie

Pat Eppler wrote:

>

>

> Angie,

>

> My name is Pat Eppler and I have also been denied twice by my PPO insurance

> and I am trying to work up a challenge to the policy. Would you mind

> telling me exactly what you did and send me a copy of your letters if you

> don't mind. I am so discouraged about their attitude. I want this so badly

> and as I am in my 50's I feel that my time is running out for this surgery!

> Thanks for any help you can give me. My email is " eppler@... " .

>

> > Re: Approved with PPO/insurance?

> >

> >

> > From: Amkm784734@...

> >

> > Hi my name is Mcintyre and I am a referral nurse with

> > Humana Ins. I

> > was denied and I have the PPO. I appealed and my appeal was denied. I

> > challenged the contract with my personal letters and Dr.

> > Rutledge's a[[eal

> > letter and I was called by the corporate benefits director

> > yesterday and told

> > that they have already faxed a addendum to the appeals dept. on

> > behalf and

> > they would be clarifying the exclusion that excludes services for the

> > treatment of obesity to be worded that is is a covered benefit if

> > you meet

> > the criteria of morbid or clinically severe obese and the medical

> > indications. tell your relative to keep fighting and do not give up.

> >

> > Angie

> >

> > ------------------------------------------------------------------------

> > Get involved. Share your thoughts!

> > http://www.onelist.com

> > Join the ONElist Weekly Survey. Go to homepage for details.

> > ------------------------------------------------------------------------

> > This message is from the Mini-Gastric Bypass List at Onelist.com

> >

>

> ------------------------------------------------------------------------

> Where do some of the Internet's largest email lists reside?

> http://www.onelist.com

> At ONElist - the most scalable and reliable service on the Internet.

> ------------------------------------------------------------------------

> This message is from the Mini-Gastric Bypass List at Onelist.com

[Guest guest]

Now since some of you have put all your efforts and energy into ins. battles

would it be un-cool to copy off you. Could you send some of your strongest

arguements and oppositions some of their responses and any battle stratagies

that you have used ,

out on the list to any and all your comrades? the more info the more paperwork

the better. perhaps a few letters from post ops that state the dramatic physical

and emotional improvement that the surgery has done for them in ins. language of

course, decreased meds, improved bp, less dr. visits you get my drift.

occationally when a post is helpful in my situation i copy it and put it in my

file any an all that would be willing to contribute stratagies and battle plans

to all our files would be appreciated

carrie

Pat Eppler wrote:

>

>

> Angie,

>

> My name is Pat Eppler and I have also been denied twice by my PPO insurance

> and I am trying to work up a challenge to the policy. Would you mind

> telling me exactly what you did and send me a copy of your letters if you

> don't mind. I am so discouraged about their attitude. I want this so badly

> and as I am in my 50's I feel that my time is running out for this surgery!

> Thanks for any help you can give me. My email is " eppler@... " .

>

> > Re: Approved with PPO/insurance?

> >

> >

> > From: Amkm784734@...

> >

> > Hi my name is Mcintyre and I am a referral nurse with

> > Humana Ins. I

> > was denied and I have the PPO. I appealed and my appeal was denied. I

> > challenged the contract with my personal letters and Dr.

> > Rutledge's a[[eal

> > letter and I was called by the corporate benefits director

> > yesterday and told

> > that they have already faxed a addendum to the appeals dept. on

> > behalf and

> > they would be clarifying the exclusion that excludes services for the

> > treatment of obesity to be worded that is is a covered benefit if

> > you meet

> > the criteria of morbid or clinically severe obese and the medical

> > indications. tell your relative to keep fighting and do not give up.

> >

> > Angie

> >

> > ------------------------------------------------------------------------

> > Get involved. Share your thoughts!

> > http://www.onelist.com

> > Join the ONElist Weekly Survey. Go to homepage for details.

> > ------------------------------------------------------------------------

> > This message is from the Mini-Gastric Bypass List at Onelist.com

> >

>

> ------------------------------------------------------------------------

> Where do some of the Internet's largest email lists reside?

> http://www.onelist.com

> At ONElist - the most scalable and reliable service on the Internet.

> ------------------------------------------------------------------------

> This message is from the Mini-Gastric Bypass List at Onelist.com

[Guest guest]

IF AND WHEN I get my surgery approved, I hope Dr R askes me to have a

web page on his site....mine will concentrate mainly on the insurance

battle, etc.... I'll try to compile a list of the sites and also a

summary of the letters I wrote......As everyone here knows, I am king of

computer idiots but I will try to forward the letters I wrote directly

to you sometime this weekend.....

Kathy

Waiting....

[Guest guest]

IF AND WHEN I get my surgery approved, I hope Dr R askes me to have a

web page on his site....mine will concentrate mainly on the insurance

battle, etc.... I'll try to compile a list of the sites and also a

summary of the letters I wrote......As everyone here knows, I am king of

computer idiots but I will try to forward the letters I wrote directly

to you sometime this weekend.....

Kathy

Waiting....

[Guest guest]

IF AND WHEN I get my surgery approved, I hope Dr R askes me to have a

web page on his site....mine will concentrate mainly on the insurance

battle, etc.... I'll try to compile a list of the sites and also a

summary of the letters I wrote......As everyone here knows, I am king of

computer idiots but I will try to forward the letters I wrote directly

to you sometime this weekend.....

Kathy

Waiting....

[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]

Janet,

YEAH!!!!! Glad to hear you got approval, copied you

letter to my relative that has PPO coverage to help

arm her in her fight!

Congrats on getting approved!

Kathy (In NC)

===

Kathy from Statesville, NC

MGB W/Dr. Rutledge 1-6-99

Pre-Op weight 330

4 months post-op 260

Partners Medicare Choice/won on appeal

_____________________________________________________________

[Guest guest]

Janet,

YEAH!!!!! Glad to hear you got approval, copied you

letter to my relative that has PPO coverage to help

arm her in her fight!

Congrats on getting approved!

Kathy (In NC)

===

Kathy from Statesville, NC

MGB W/Dr. Rutledge 1-6-99

Pre-Op weight 330

4 months post-op 260

Partners Medicare Choice/won on appeal

_____________________________________________________________

[Guest guest]

Janet,

YEAH!!!!! Glad to hear you got approval, copied you

letter to my relative that has PPO coverage to help

arm her in her fight!

Congrats on getting approved!

Kathy (In NC)

===

Kathy from Statesville, NC

MGB W/Dr. Rutledge 1-6-99

Pre-Op weight 330

4 months post-op 260

Partners Medicare Choice/won on appeal

_____________________________________________________________