Tachia/Request for information

[Guest guest]

Hi Tachia,

I like the spelling of your name; great variation! Welcome!

To answer your question, I did get my upcoming DS surgery approved

out-of-network. Well, it was denied at first because they said it

(gastric bypass) was available IN-plan. But then I appealed, showing

that the BPD/DS was unique and different from the RNY offered in-

plan. Since they had no DS surgeons in-plan, they granted me the

appeal.

My DS surgeon, Dr Pomp is in-state, but out-of-network. Don't know

if things would be different if there were no DS docs in-state or if

they were not accepting new patients...

You may need to start the ball rolling by paying out-of pocket for a

consult with Dr Booth (or whomever is your chosen surgeon). Then you

can let them submit all your medical necessity to insurance for you.

If you get a denial (and you probably will regardless of how good

your case is because you have an HMO, like me) you can then appeal

and that is the time to make your case if they don't have a DS

surgeon in-plan.

When you get to that point, I have put sample letters to insurance co

in the fles section of this list. You are welcome to use them if you

think they can help. If/when you get approved, you can have your

surgeon try to re-submit the consultation appt charges and maybe you

will get payment for that.

Good luck, Tachia. It is not an easy journey, but it is Oh, so worth

it! Keep in touch!

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

> I am very interested in the DS surgery, and BCBS (HMO policy) has

> approved the RNY procedure. There is only one doctor in Atlanta

that

> does the DS surgery and Dr. is not accepting new patients for

a

> while. I have tried Dr. Booth in MS, but the insurance company will

> not accept him since he is out of network.

>

> Has anyone insurance company covered an out-of-state procedure?

> What can I do to get them to accept Dr. Booth's services?

> Can you recommend any steps to possibly getting the insurance

company

> to accept the DS procedure?

>

> Your assistance would be greatly appreciated.

>

> Thanks,

> Tachia