Re: PacifiCare PPO

[Guest guest]

Hello,

Has anyone gotten approval for WLS with PacifiCare PPO???? My

insurance is changing to this and the preliminary checking has met with an

exclusion for any treatment for Obesity. I told the representative that

'Morbid Obesity " was a very different diagnosis but she repeated that the

PPO plan has an exclusion. Why do the HMOs cover this and not the PPO's?

Does anyone have take on this??? Again, has anyone gotten PacifiCare PPO to

pay for their DS, even under a different diagnosis like gastric bypass to

treat co-morbidities? I am stressing big time.

Janice in Texas

[Guest guest]

Hello, Has anyone gotten approval for WLS through PacifiCare PPO?I just called them and they say there is an exclusion for any treatment for'Obesity'. I said that is a completely different diagnosis than 'MorbidObesity' or 'Clinically Severe Obesity'. She still said no. I have sent mypapers in for a Pre-determination of therapy for WLS but the wait timeconflicts with my need to get plane tickets for my consult with my surgeon.If I knew they DO cover the DS then I would go ahead and make my consultappointment and wait for payment after the fact but I would hate to pay theapprox. $1000 dollars of all involved costs for getting to the consult ifthere was no chance of them approving the surgery and consult. I hadPacifiCare HMO where I was approved for gastric bypass surgery but wasdenied from going out of network. Now my insurance is changing toPacifiCare PPO and I can go out of network but now the approval is inquestion. HELP!!!???Thank you,

Janice in Texas

[Guest guest]

Hi Janice,

I'm not sure about the Pacific Care PPO but I had the same exclusion

in my Pacific Care HMO policy. I just ignored it and all the policy

experts that said I couldn't have the surgery and I carried on with

my mission to have DS. I may have been one of the very lucky ones but

I was approved. I did have to write a letter to them that my Dr. sent

in with the LOMN. They would have wanted me to go to San Diego for

the RNY. In the letter I mentioned that I was a canidate for the

surgery based on the NIH guidlines, Listed my medical problems and

those of my family history I faced without getting surgery, a list of

all the diets I failed at in the past and lastly why I wanted the DS

over the RNY. gave me permission to attach information as

backup from the DS website as well as the Hess/Rabkin reports. Best

of luck to you.

Cassandra

DS 4/16/01 Dr. Keshishian

> Hello, Has anyone gotten approval for WLS through PacifiCare PPO?

> I just called them and they say there is an exclusion for any

treatment for

> 'Obesity'. I said that is a completely different diagnosis

than 'Morbid

> Obesity' or 'Clinically Severe Obesity'. She still said no. I

have sent my

> papers in for a Pre-determination of therapy for WLS but the wait

time

> conflicts with my need to get plane tickets for my consult with my

surgeon.

> If I knew they DO cover the DS then I would go ahead and make my

consult

> appointment and wait for payment after the fact but I would hate to

pay the

> approx. $1000 dollars of all involved costs for getting to the

consult if

> there was no chance of them approving the surgery and consult. I

had

> PacifiCare HMO where I was approved for gastric bypass surgery but

was

> denied from going out of network. Now my insurance is changing to

> PacifiCare PPO and I can go out of network but now the approval is

in

> question. HELP!!!???

> Thank you,

> Janice in Texas