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Rocksjourney13

Rant in 3,2,1

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Okay I wanted to start off by saying I am glad I have a place like this to turn to as I continue to creep through my "journey" at a snails pace. I have no one in my life to talk to about this as I have kept this part of my life private from everyone except my husband. He does not have a weight problem so though he listens he does not understand what I am going through.

I attended the WLS seminar on June 24, 2013, yes that's right over a year ago with no surgery in sight and already 2 rejections under my belt from my insurance, the latest of which came this past Thursday.

After doing all the classes, seeing the NUT, psychologist, and every other requirement classes they had, following the program for over 9 months I was rejected because they said that I did not have any co-morbitities and would only approve me if I could produce a weight history from my physician of over 2 years that showed me at the constant BMI that is required for patients that have no co-morbitities and if it was presented by my surgeon in a peer to peer forum. Well this peer to peer was done on 6/25/2014 a year after attending the first WLS Seminar. The surgeon also mentioned the osteoarthritis in my knees and hips which he attributed to my weight and my inability to stay on a routine exercise schedule due to the pain I endure during exercising and even just everyday walking and normal activities. My surgeon was told that now they would require a 6 month treatment for my osteoarthritis and I could appeal in 6 months if my pain has not improved. Are they F'n kidding?????????????

I have done everything they required and they keep coming up with something new. The coordinator at WLS office said she has never seen anything like it and said it is actually the employer not the insurance company putting the restrictions/ new qualifications. Is this legal? Does anyone have any advise on how I can make them see that this is out of medial need and not a vanity thing for me. It seems like they require people to be in extremely poor health (which at this point I feel that mine continues to get worse) before they will do anything to help. How can they not see that as my health gets worse and deteriorates they will have far exceeded the cost of this surgery by paying for all the diseases I will surely get from morbid obesity. Perhaps they are hoping my obesity will kill me sooner than later. Ughhhhh!!

I am usually not a person that gets down and I always am willing to fight the good fight. I even found myself stepping away from this forum as I find myself increasingly jealous of all you who are succeeding with your sleeve. I am not that person but I find I am becoming her. So jealous of those who post they already have a date after going through the process for 4 months.... don't get me wrong I am happy for you I just wish I could get there too.

I don't want to go the Mexico route as I really feel the insurance company is in the wrong. We continue to pay our premiums and they should live up to providing service when medically needed. Anyone else have a problem getting approved that they were able to eventually overcome. I really need your help.

If you made it to the end of this rant I applaud you, It is beyond long, thanks for listening, any advice will be appreciated.

Thanks again.

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  1. slags68's Avatar
    Have you asked them to give you the written wording of your coverage? I know the program I worked with always suggested trying to get the info in writing. Then you could always contact the State board of insurance in your state to see if they can clarify if there is anything else you can do to appeal.
  2. heyheypaula's Avatar
    So sorry that you are going through this, dealing with insurance companies make me want to tear my hair out.

    DH's insurance is from the union he belonged to when he retired, and they were the ones that did not have WLS coverage built in to the policy. I went the Mexico route because I did not feel like pursuing this, only making myself sick over fighting with them. Unfortunately, insurance companies in this country have been allowed to do things like this for far too long. They are laughing all the way to the bank taking our money. I'm sorry if some don't agree, this is my personal opinion and I am owning it.

    Good luck and I hope you get the resolution that you want and that you are entitled to.
  3. dbcassidy's Avatar
    Sounds like the company you work for is self-insured (and therefore gets to make their own rules).

    You can appeal the decision without having to wait the six months your insurance company wants you to wait: See the following: https://www.healthcare.gov/how-do-i-...cision/#part=1 and How to Appeal a Health Insurance Denial - Health - WSJ.com

    I would first file an internal appeal and if you are still denied, file an external review.
    Updated 06-29-2014 at 05:07 PM by dbcassidy (Added WSJ article)
  4. Peachybroo's Avatar
    I'm sorry that is the situation you are going through. I too could not get my insurance to cover the procedure...it didn't matter that I weighed over 450 lbs. It was absolutely ridiculous. I agree that the insurance is in the wrong and that they SHOULD cover that procedure for you. However, if you ever get to the point where you still can't get it approved and find that you need to take matters in your own hands, don't completely rule out Mexico. It is a different culture and experience but being 5 days post op I seriously have ZERO regrets about choosing that option. My surgeon was EXTREMELY SKILLED in this specific procedure...has literally done thousands of the Gastric Sleeve. (And that seems to be a huge benefit compared to some complications I am seeing on here from people who had it done here in the US) For me personally, something had to change. You are in my thoughts and I hope you can get the outcome you are looking for with your surgeon and insurance.
  5. Rerun4u2's Avatar
    I feel your pain as it took me 18 months to tread through insurance policies. My doctors were instrumental in writing letters on my behalf. Good Luck to you. Don't give up.
  6. rescue's Avatar
    I'm sorry you are dealing with this crap from the insurance company. Mine doesn't cover WLS so Mexico here I come. Even if they did cover it I would be too impatient to wait so long for an approval. .. they make you jump through so many hoops to get approved.. I've read many stories about it on this site.. I've already been to Mexico for a lap band and was blown away from the utmost superior care I received. Please don't rule out mexico, I know it can be a very big step. You will find so many people on this site that have had a positive experience. Best wishes to you.
  7. dietingdonna's Avatar
    My insurance wont cover ANYTHING bariatric so I went to Tijuana. I dont regret it at all.

    I understand your will to fight them and thats what I would do! Make them give you everything in writing, get your doctor to write a formal letter saying you would benefit from WLS and keep fighting! The squeaky wheel gets the grease ya know. I would call them everyweek or daily if I had too!
  8. Joybe's Avatar
    My insurance would not cover the surgery either. The tests I was required to have done prior to surgery, they covered, maybe they did not know what they were for. Keep moving forward. Do not let them discourage you. If this is the right route for your journey, you will find a way. It may not be easy, but it will be worth it!