Guest guest Posted July 19, 2001 Report Share Posted July 19, 2001 . United Healthcare is pulling the same shit with me.. In florida, we have a statewide provider assistance program.. which means.. once you are denied thru the insruance company and have exhausted all of your appeals, you can give them your case to review. They have the power to overturn the insurance companies determination.. I had my hearing yesterday and I will know if I won in 15 days.. I think I might have but Im afraid to hope.. Good luck with your fight.. dont give up.. you are worth the effort! Sue. > I need info. My insurance (BCBS of california PPO) has denied me for > ds surgery they say it is investigational. they will pay for > roux-en-y but not ds. they stopped paying for ds this year ( they > have paid for it in the past). I need to know if there is anything > that i can do in an appeal to convince them to let me have the ds > surgery. Any info would be greatly appreciated. > > Thanks, Woods Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2001 Report Share Posted July 19, 2001 OK, Please make a formal request to find out their basis for their claim of investigational. Then check out to see if their references are credible and up to date. Then provide them with the recent papers by Hess,Scopinaro, and Baltasar that show very large studies over long periods of time. Aetna has also been a problem. Aetna publishes their policy at: http://www.aetnaushc.com/cpb/data/CPBA0157.html I am preparing for the worst, but hoping for the best. My company uses Aetna as a third-party adminstrator, so I think they will be more liberal. I really belive that we need to get all the bogus negative information on DS and refute it point by point. I would like to get to a point that all of us can send a single packet to any insurance company and not only approval, but overturn these bogus policies. I just haven't had time to go to the medical library to collect all the relavant references. If anybody can find any of these for me it would be much appreciated. Thanks, Hull 1. National Institutes of Health Consensus Development Conference Statement. Gastrointestinal Surgery for Severe Obesity. March 25 - 27, 1991; 9: 1 - 20. 2. Sugarman HJ. Surgery for morbid obesity. Surgery 1993;114:865 - 7. 3. McLean LD, Rhode BM, Sampalis J, Forse KA Results of the surgical treatment of obesity. Am J Surg 1993;165:155 - 59. 4. Scopinaro N, Gianetta E, Friedman D et al. Biliopancreatic diversion for obesity. Problems Gen Surg 1992;9:362 - 79. 5. Grimm IS, Schindler W, Haluszka O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion. Am J Gastroenterol 1992;87:775 - 79. 6. Langdon DE, Leffigwell T, Rank D. Hepatic failure after biliopancreatic diversion. Am J Gastroenterol 1993;88:321. 7. Fisher BL, Barber AE. Gastric bypass procedures. Eur J Gastroenterol Hepatol 1999 Feb;11(2):93 - 7. 8. Deitel M. Surgery for morbid obesity. Overview. Eur J Gastroenterol Hepatol 1999 Feb;11(2):57 - 61. 9. Wylezol M, Pardela M. Contemporary methods of treatment of morbid obesity. Pol Merkuriusz Lek 1998 Aug;5(26):95 - 7. 10. Forestieri P, De Luca M, Formato A, Loffredo A, et al. Restrictive versus malabsorptive procedures: criteria for patient selection. Obes Surg 1999 Feb;9(1):48 - 50. 11. Carmichael AR. Treatment for morbid obesity. Postgrad Med J 1999 Jan;75(879):7 - 12. 12. 16th Annual Meeting of the American Society for Bariatric Surgery. San Diego, California, USA. June 9 - 12, 1999. Abstracts. Obes Surg 1999 Apr;9(2):123 - 44. > I need info. My insurance (BCBS of california PPO) has denied me for > ds surgery they say it is investigational. they will pay for > roux-en-y but not ds. they stopped paying for ds this year ( they > have paid for it in the past). I need to know if there is anything > that i can do in an appeal to convince them to let me have the ds > surgery. Any info would be greatly appreciated. > > Thanks, Woods Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 17, 2005 Report Share Posted August 17, 2005 Okay I'm so totally upset. I just found out my company is switching insurance as of October 1st. I've gone through all the process' and I am just waiting for the approval of my referral to see the surgeon. I'm almost ready to give up I figure I've done all of this and the surgery is not even going to happen. Not before October 1st there's no way. What do you guys have to say??? Thanks, Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 17, 2005 Report Share Posted August 17, 2005 Hi - i am not sure how that works....................i knew a woman who had her surgery approved and had a surgery date three months out and her whole ins plan changed and the new ins carrier honored that and she got to have her surgery, but since you havent got a date yet, i am just not sure how that all works good luck with it, and pray for patience colleenda6bearz wrote: Okay I'm so totally upset. I just found out my company is switching insurance as of October 1st. I've gone through all the process' and I am just waiting for the approval of my referral to see the surgeon. I'm almost ready to give up I figure I've done all of this and the surgery is not even going to happen. Not before October 1st there's no way. What do you guys have to say???Thanks, Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 17, 2005 Report Share Posted August 17, 2005 Can you switch to a Kaiser personal advantge plan, at least till your surgery is done? My Kaiser insurance changed in January- i just had higher co-pays, but it was worth keeping kaiser then switching to another, where i didnt know what their WLS requirements were, Besides we love our PCP! Castro > Okay I'm so totally upset. I just found out my company is switching > insurance as of October 1st. I've gone through all the process' and I > am just waiting for the approval of my referral to see the surgeon. I'm > almost ready to give up I figure I've done all of this and the surgery > is not even going to happen. Not before October 1st there's no way. > What do you guys have to say??? > > Thanks, > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 17, 2005 Report Share Posted August 17, 2005 That is a HUGE disappointment. Try to phone the new health plan and inquire as to whether or not WLS is a covered benefit, and if so, what is the criteria. Pam b --- da6bearz da6bearz@...> wrote: > Okay I'm so totally upset. I just found out my > company is switching > insurance as of October 1st. I've gone through all > the process' and I > am just waiting for the approval of my referral to > see the surgeon. I'm > almost ready to give up I figure I've done all of > this and the surgery > is not even going to happen. Not before October 1st > there's no way. > What do you guys have to say??? > > Thanks, > > > > > __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 17, 2005 Report Share Posted August 17, 2005 But that would only work if the new plan covers the procedure... Pam b --- Colleen Garner irishlilt@...> wrote: > Hi - > > i am not sure how that works....................i > knew a woman who had her surgery approved and had a > surgery date three months out and her whole ins plan > changed and the new ins carrier honored that and she > got to have her surgery, but since you havent got a > date yet, i am just not sure how that all works > good luck with it, and pray for patience > colleen > > da6bearz da6bearz@...> wrote: > Okay I'm so totally upset. I just found out my > company is switching > insurance as of October 1st. I've gone through all > the process' and I > am just waiting for the approval of my referral to > see the surgeon. I'm > almost ready to give up I figure I've done all of > this and the surgery > is not even going to happen. Not before October 1st > there's no way. > What do you guys have to say??? > > Thanks, > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 17, 2005 Report Share Posted August 17, 2005 Just a note... You would not qualify for Kaiser's Personal Advantage plan as you have pre-exisitng conditions, (and a big one at that). There is another plan entitled Conversion; however, at least when I was still working there, Kaiser would not allow a member whose employer is changing insurance carriers to convert to the individual conversion plan. I once asked a Kaiser Marketing rep why that was, and was told that it was because it was the hope that if enough employees were pissed about losing their Kaiser, (with no possibility of converting for an individual plan), they would go to Human Resourses, complain, and possibly change the employer's mind about switching carriers! I can tell you, though, that as a Member Services Rep for Kaiser, I once had a member, who, if memory serves, had cancer and was going thru treatment and did not want to switch her oncologist, but her employer was changing health plans. I don't know if Kaiser appreciated this, but, I spoke with her Human Resources dept and had them fax a termination of coverage request to Kaiser with a term date of one month prior to the company terming their account with KP. I then kept in close contact with Kaiser's Accounting dept to ensure that an offer for conversion was sent to the member, (which it was). Thus, the member was able to convert to an individual plan... Hope this helps... Pam b --- sarahbear74@...> wrote: > Can you switch to a Kaiser personal advantge plan, > at least till your > surgery is done? > My Kaiser insurance changed in January- i just had > higher co-pays, but > it was worth keeping kaiser then switching to > another, where i didnt > know what their WLS requirements were, Besides we > love our PCP! > Castro > > > > > > > > > Okay I'm so totally upset. I just found out my > company is switching > > insurance as of October 1st. I've gone through > all the process' and I > > am just waiting for the approval of my referral to > see the surgeon. I'm > > almost ready to give up I figure I've done all of > this and the surgery > > is not even going to happen. Not before October > 1st there's no way. > > What do you guys have to say??? > > > > Thanks, > > > > > > > > __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 18, 2005 Report Share Posted August 18, 2005 ps If you do this, however, you will need to continue to pay for the KP conversion plan until such time as your company has open enrollment, at which time you would be able to enroll onto the new carrier. Most employers, unless very small, (or the Feds, if memory serves), will not allow its employees to switch or enroll onto a new health plan outside of open enrollment. Exclusions of this policy would include divorce, marriage, new child, (whether adoption or giving birth), new employee, exiting employee, child aging off, and, of course, death! Pam b --- Pamela florenceboss@...> wrote: > Just a note... You would not qualify for Kaiser's > Personal Advantage plan as you have pre-exisitng > conditions, (and a big one at that). There is > another > plan entitled Conversion; however, at least when I > was > still working there, Kaiser would not allow a member > whose employer is changing insurance carriers to > convert to the individual conversion plan. I once > asked a Kaiser Marketing rep why that was, and was > told that it was because it was the hope that if > enough employees were pissed about losing their > Kaiser, (with no possibility of converting for an > individual plan), they would go to Human Resourses, > complain, and possibly change the employer's mind > about switching carriers! > > I can tell you, though, that as a Member Services > Rep > for Kaiser, I once had a member, who, if memory > serves, had cancer and was going thru treatment and > did not want to switch her oncologist, but her > employer was changing health plans. I don't know if > Kaiser appreciated this, but, I spoke with her Human > Resources dept and had them fax a termination of > coverage request to Kaiser with a term date of one > month prior to the company terming their account > with > KP. I then kept in close contact with Kaiser's > Accounting dept to ensure that an offer for > conversion > was sent to the member, (which it was). Thus, the > member was able to convert to an individual plan... > > Hope this helps... > > Pam b > --- sarahbear74@...> wrote: > > > Can you switch to a Kaiser personal advantge plan, > > at least till your > > surgery is done? > > My Kaiser insurance changed in January- i just had > > higher co-pays, but > > it was worth keeping kaiser then switching to > > another, where i didnt > > know what their WLS requirements were, Besides we > > love our PCP! > > Castro > > > > > > > > > > > > > > > > > Okay I'm so totally upset. I just found out my > > company is switching > > > insurance as of October 1st. I've gone through > > all the process' and I > > > am just waiting for the approval of my referral > to > > see the surgeon. I'm > > > almost ready to give up I figure I've done all > of > > this and the surgery > > > is not even going to happen. Not before October > > 1st there's no way. > > > What do you guys have to say??? > > > > > > Thanks, > > > > > > > > > > > > > > > > > __________________________________________________ > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 18, 2005 Report Share Posted August 18, 2005 Well I did talk to the surgeon's office today and they told me they do take my new insurance and the the new insurance should except everything I've done with Kaiser. So that did make it sound a whole lot better. I should have a date prior to October 1st so hopefully that will help. Thanks for listening, Pamela wrote: But that would only work if the new plan covers theprocedure...Pam b--- Colleen Garner wrote:> Hi -> > i am not sure how that works....................i> knew a woman who had her surgery approved and had a> surgery date three months out and her whole ins plan> changed and the new ins carrier honored that and she> got to have her surgery, but since you havent got a> date yet, i am just not sure how that all works> good luck with it, and pray for patience> colleen> > da6bearz wrote:> Okay I'm so totally upset. I just found out my> company is switching > insurance as of October 1st. I've gone through all> the process' and I > am just waiting for the approval of my referral to> see the surgeon. I'm > almost ready to give up I figure I've done all of> this and the surgery > is not even going to happen. Not before October 1st> there's no way. > What do you guys have to say???> > Thanks,> > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 19, 2005 Report Share Posted August 19, 2005 Wonderful news, !!!! Pam b --- Blair da6bearz@...> wrote: > Well I did talk to the surgeon's office today and > they told me they do take my new insurance and the > the new insurance should except everything I've done > with Kaiser. So that did make it sound a whole lot > better. I should have a date prior to October 1st > so hopefully that will help. > > Thanks for listening, > > > > Pamela florenceboss@...> wrote: > But that would only work if the new plan covers the > procedure... > > Pam b > > --- Colleen Garner irishlilt@...> wrote: > > > Hi - > > > > i am not sure how that works....................i > > knew a woman who had her surgery approved and had > a > > surgery date three months out and her whole ins > plan > > changed and the new ins carrier honored that and > she > > got to have her surgery, but since you havent got > a > > date yet, i am just not sure how that all works > > good luck with it, and pray for patience > > colleen > > > > da6bearz da6bearz@...> wrote: > > Okay I'm so totally upset. I just found out my > > company is switching > > insurance as of October 1st. I've gone through all > > the process' and I > > am just waiting for the approval of my referral to > > see the surgeon. I'm > > almost ready to give up I figure I've done all of > > this and the surgery > > is not even going to happen. Not before October > 1st > > there's no way. > > What do you guys have to say??? > > > > Thanks, > > > > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
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