Jerry/overcoming insurance problem

[Guest guest]

Jerry,

How very frustrating for you! If your PCP is on board with you,

his/her help will be invaluable. My insurance did not have these

restrictions spelled out. They simply said they would not pay for

treatment for obesity or weight loss. Period. While I was prepared

to point out the MO/O difference, I never had to. I provided my PCP

and surgeon with a hand written diet history which I assume made it

into my insurance 'application'. I never supplied any doctor with

any actual documentation or proof that I had done what I said I had

done.

I'm not saying to lie to your insurance or anything, but if you had

been going to your PCP for routine visits over the past year or,

better still for 3 of the past 5 years and you were weighed in

his/her office you should be OK. If your PCP writes a letter of

medical necessity, just make sure it states that you have been

continuously treated in his/her office for your super-morbid-obesity

for x years with limited success. Or something to that effect.

I would also email Walter to get his insight. He won't do anything

for you until you get that first denial. But if you get denied and

have a gut feeling they are not going to budge, it is better to bring

Walter in earlier than later.

Good Luck, Hun. I will send you copies of my doc's letters hopefully

tomorrow sometime. All my prayers and best wishes,

Terri Hassiak

BMI 60

http://www.obesityhelp.com/morbidobesity/profile.phtml?N=H980366398

Appealed " Out-of-Network " Ins. Denial - AND WON!!!

BPD/DS with Dr. Pomp on 6/25/01

email(no spaces): bunsofluff @ hotmail.com

> 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