overcoming insurance problem

[Guest guest]

HELP! My husband's employer has a self insured plan that works through

American Life Care and uses Beech Steet Providers. I saw Dr. Booth the

first week of Feb. and have been waiting ever since. Just last week I

called about a different matter and decided to ask about the WLS

approval...well, the lady who had been working it is no longer with the

company so...of course, that's the story that my claim kinda " fell though

the cracks " . Not only that! The employer had given us the wrong policy

book....from the old provider. I got a new booklet yesterday and the

" rules " have changed!! They say that I must meet all of the following:

1. Be 200% over the upper limit for my weight on the chart....check, with

a BMI of 67 -68 I got that covered!

2. Have been obese at least 5 years....check, I am 43, been obese (over

100 lbs over) since about 22 or so.

3. Have a documented history of participation in medically supervised

weight reduction programs for at least 3 of the 5 years...well, I may have 3

years of " programs " I've tried but not 3 years of " medically supervised "

programs.

4. have participated in a medically supervised weight-loss program with

weekly attendance for at least 6 months during last year...nope, had given

up on " diet programs " decided it was healthier to just be big than to keep

up the " yo-yo " .

5. have attended and complied with nutritional counseling and exercise

programs under the guidance of their pcp during the last year...see # 4.

6. be an acceptable age and risk for surgery...Dr. Booth says I am...also

will be seeing a new PCP since my old one thinks WLS is a " tragedy " that

people do to themselves.

Okay, ya'll...has anyone overcome this kind of restriction? If they deny me

the first go round....has anyone over come this in appeal? I have begun

gathering pictures of me over the last 20 years or so, doctor's records,

mother's journal entries (she's passed away) concerning my weight and our

joint efforts to help me, etc.

Any ideas or help greatly appreciated! I am mad but also so afraid that I

will not be able to get the help I so desperately need. Of course, they

don't pay for anything else for weight loss so all the programs that they

require would have been self paid. Also, all they would prove is that I can

lose weight...Been there...done that...but they don't prove that IT WILL

STAY OFF! Even if I go for the 6 months now, and lose 100 pounds or so on

some kind of liquid diet, I WILL STILL BE MORBIDLY OBESE!! HHHMMMM, I know

that some get around the wording by claiming morbid obesity not just

obesity....wonder if I can claim " class 3 super morbid obesity " instead of

just simple " morbid obesity " ?? Am I just grasping at straws?? I feel that

they just want to claim that they cover the surgery but want to restrict it

so that it makes it almost impossible to meet all the rules. How many

people have 3 years of medically supervised care out of the last 5 years???

Could even Walter overcome this? Sorry so long!

Thanks,

Jerry

_________________________________________________________________

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[Guest guest]

Jerry:

Your message contains good news and bad news. Since the plan is self

insured understand that the FINAL decision lies with the employer and that

the administrators only make recommendations. That means that if you can

convince someone at the company how much you need the surgery you will

probably be able to get it.

The bad news is the rules. They are clearly overly restrictive and very few

of us could ever qualify under them. I'd suggest the following plan of

action.

1. Go to your surgeon's office and ask them to prepare a letter of medical

necessity for you.

2. Get your PCP to also write a LOMN, faxing a copy to the surgeon's

office.

3. When everything is ready, hand carry it into the person in your

husband's company who works with the insurance administrators. Explain to

them how much happier and better employee your DH would be if you got the

surgery.

4. If doesn't appear to be working, remind them that you understand that

the requirements are totally unreasonable to discourage cosmetic surgeries

but your situation is much more grave and as it really is medically

necessary they could be liable if something were to happen to you due to the

lack of surgery.

5. Finally, consider hiring Walter Lindstrom to work for you. I don't have

his e-mail address but he has done miraculous things for some who had hard

exclusions. And if you get to that need there are many here on the list who

can give it to you.

Good luck and don't quit trying.

Regards.

Joe Frost, old gentleman, not old fart

San , Tx., 60 years old

Surgery 11/29/00 by Dr. Welker

Lateral Gastrectomy with Duodenal Switch

340 Starting Weight, currently 237

http://www.duodenalswitch.com/Patients/Joe/joe.html

http://recovery.hiwaay.net/

>

> HELP! My husband's employer has a self insured plan that works

> through

> American Life Care and uses Beech Steet Providers. I saw Dr. Booth

> the

> first week of Feb. and have been waiting ever since. Just last week

> I

> called about a different matter and decided to ask about the WLS

> approval...well, the lady who had been working it is no longer with

> the

> company so...of course, that's the story that my claim kinda " fell

> though

> the cracks " . Not only that! The employer had given us the wrong

> policy

> book....from the old provider. I got a new booklet yesterday and the

> " rules " have changed!! They say that I must meet all of the

> following:

> 1. Be 200% over the upper limit for my weight on the

> chart....check, with

> a BMI of 67 -68 I got that covered!

> 2. Have been obese at least 5 years....check, I am 43, been obese

> (over

> 100 lbs over) since about 22 or so.

> 3. Have a documented history of participation in medically

> supervised

> weight reduction programs for at least 3 of the 5 years...well, I may

> have 3

> years of " programs " I've tried but not 3 years of " medically

> supervised "

> programs.

> 4. have participated in a medically supervised weight-loss program

> with

> weekly attendance for at least 6 months during last year...nope, had

> given

> up on " diet programs " decided it was healthier to just be big than to

> keep

> up the " yo-yo " .

> 5. have attended and complied with nutritional counseling and

> exercise

> programs under the guidance of their pcp during the last year...see #

> 4.

> 6. be an acceptable age and risk for surgery...Dr. Booth says I

> am...also

> will be seeing a new PCP since my old one thinks WLS is a " tragedy "

> that

> people do to themselves.

>

> Okay, ya'll...has anyone overcome this kind of restriction? If they

> deny me

> the first go round....has anyone over come this in appeal? I have

> begun

> gathering pictures of me over the last 20 years or so, doctor's

> records,

> mother's journal entries (she's passed away) concerning my weight and

> our

> joint efforts to help me, etc.

> Any ideas or help greatly appreciated! I am mad but also so afraid

> that I

> will not be able to get the help I so desperately need. Of course,

> they

> don't pay for anything else for weight loss so all the programs that

> they

> require would have been self paid. Also, all they would prove is

> that I can

> lose weight...Been there...done that...but they don't prove that IT

> WILL

> STAY OFF! Even if I go for the 6 months now, and lose 100 pounds or

> so on

> some kind of liquid diet, I WILL STILL BE MORBIDLY OBESE!! HHHMMMM,

> I know

> that some get around the wording by claiming morbid obesity not just

> obesity....wonder if I can claim " class 3 super morbid obesity "

> instead of

> just simple " morbid obesity " ?? Am I just grasping at straws?? I

> feel that

> they just want to claim that they cover the surgery but want to

> restrict it

> so that it makes it almost impossible to meet all the rules. How

> many

> people have 3 years of medically supervised care out of the last 5

> years???

> Could even Walter overcome this? Sorry so long!

> Thanks,

> Jerry

> _________________________________________________________________

> Get your FREE download of MSN Explorer at http://explorer.msn.com

> --- End forwarded message ---

>

>

>

[Guest guest]

I love the bait-and-switch on the terms of your policy. They " gave you the

wrong policy book " ?

Your policy itself is just absurd. Talk to Walter Lindstrom. Call now,

before you try to appeal. In the long run, you will save yourself heartache

and even money by having it properly handled.