Catch 22 I can't believe this

[Journey Tobeme]

Sorry fort the typos. I'm on my phone and this site won't let me edit.

My appeal was denied. The reason is because I lost 38 pounds in the last year. My surgeon requires all patients to lose 10%. That would be 26 pounds for me. Since I lost Moyer than 26. The insurance company deems that as successful weight loss and denied me.

I had asked my surgeons office if that was a possibilty. I was assured by then and insurance I would not be denied if I lost any weight or over that amount. According to my denial the fact I lost any weight makes me ineligible for coverage. But my surgeon wouldn't file my insurance referral until I lost it.

Not I can't get my insurance to consider unless I go a year from August with no weight loss but supervised by a nutritionist and doctor. I can't afford to pay out of pocket for surgery in Mexico and my credit isn't good to have it financed. I won't be getting surgery because this was my only hope to afford it. I borrowed money to meet the criteria appointments. I will be paying it back for the next year so I won't be able to save. My criteria will expire before insurance will reconsider so I would have to start over from square 1.

I am so devastated. I did everything I was asked and got caught in a catch 22. My surgeon office said they will gladly monitor for the next year. But Zzz i would have to pay $75 a month for the appts and then redo all the testing and evaluations out of picket again.

Oh well it wasn't meant to be for me. Good luck to everyone!!!

[rntwinsmommy]

I would appeal and appeal and appeal and be the ins companies worse nightmare. Don't roll over and play dead. Go get what you want!!

[Sarasjourney]

I am so sorry you were denied. I think that's absolute horse puckey that they would deny you because you SLIGHTLY exceeded the weight loss requirement. I know I lost 39lbs (though I didn't keep all of it off) when my requirement was 20lbs. I would've been livid beyond belief if my insurance thought that meant I had the ability to lose on my own, thus nulling the surgery.

So is there no way you could afford to take the insurance up on their offer of a year without weight loss in order to be considered again? I wish there was something I could do for you, some kind of magic advice. But really I am so sorry and I'm so mad for you, you really got caught in it and that's an entire world of unfair.

I wish you the best of luck and I hope somewhere down the road you can have this surgery.

[Journey Tobeme]

My only appeal option at this point is to the state insurance board. I would have hire an attorney to represent me and pay all associated cost. I spoke to ask attorney who read the plan benefit book and the denial stuff. He said they would win at the state level because it is clear all attempts at weight loss must fail according to their criteria. But under their criteria it also say: must meet all surgeons criteria which includes weight loss. That is the only thing we have to stand on. His fee however would be 3k. That's almost enough to have surgery in Mexico.

Sara thank you. I wish you success. You have worked hard and I am happy for you.

[BillyJ]

I don't know your financial circumstances but have you thought of legal aid? Does your BMI still meet the criteria? Isn't there an insurance advocate at your surgeons office? Sometimes the surgeons office will go to bat for you. I hope it all works out.

[zmdh39]

Sorry fort the typos. I'm on my phone and this site won't let me edit.

My appeal was denied. The reason is because I lost 38 pounds in the last year. My surgeon requires all patients to lose 10%. That would be 26 pounds for me. Since I lost Moyer than 26. The insurance company deems that as successful weight loss and denied me.

I had asked my surgeons office if that was a possibilty. I was assured by then and insurance I would not be denied if I lost any weight or over that amount. According to my denial the fact I lost any weight makes me ineligible for coverage. But my surgeon wouldn't file my insurance referral until I lost it.

Not I can't get my insurance to consider unless I go a year from August with no weight loss but supervised by a nutritionist and doctor. I can't afford to pay out of pocket for surgery in Mexico and my credit isn't good to have it financed. I won't be getting surgery because this was my only hope to afford it. I borrowed money to meet the criteria appointments. I will be paying it back for the next year so I won't be able to save. My criteria will expire before insurance will reconsider so I would have to start over from square 1.

I am so devastated. I did everything I was asked and got caught in a catch 22. My surgeon office said they will gladly monitor for the next year. But Zzz i would have to pay $75 a month for the appts and then redo all the testing and evaluations out of picket again.

Oh well it wasn't meant to be for me. Good luck to everyone!!!

Many people will argue me into the ground when I talk about various insurances, the hoops they have you jump through to get approved for surgery and all that jazz, but I have personally seen, experienced, and been told from those very people who work within the industry, how the requirements to get insurance to pay for bariatric surgery actually came into place.

Feel free to take what I am about to say with a grain of salt, I know that many people out there hold very strong opinions on this matter, and they will probably say that what I am about to tell you is BS, idiotic, or completely false...but here we go anyway...

The ability and willingness for an insurance company to pay for your weight loss surgery is dependent on an number of factors...a lady asked a very similar question few months back, so I will post the links here, in which I answered why insurance companies make people jump through these hoops only to deny them. Click on the links to read my original answers to this question: http://www.gastricsleeve.com/forum/t...tml#post465902

This is the same thread, but an addition upon the first response that I gave the lady, so it has additional information on the subject:

http://www.gastricsleeve.com/forum/t...it-plan-4.html

The fact is that many insurance companies actually implemented these requirements, not with the intent of helping wls patients be more successful after receiving wls...they were simply implementations, that sounded logical to people seeking wls, but were actually put in place to give insurance companies numerous ways to deny your claim, hoping that you will either give up, so that they can negate paying for the surgery, or they can force you into appealing several times, hoping to run out the clock until you either change insurance companies, or run you around a series of appeals processes in which you lose enough weight to no longer qualify, or you have proven that you are not giving up, and the insurance company paying for your surgery might actually be beneficial for the companies long term profits.

Now, do not misunderstand what I am saying here...I am not saying that for some people, these requirements provide no benefit to the patient...in fact, a number of people find that the 6 month diets, nutritional counseling, and psych appointments are very helpful for wls patients long term success...but there are just as many patients that went through none of that, and have had great success.

In any case, none of that information is really a benefit to your particular situation unless it makes you reconsider appealing the decision from your insurance company. So I will add this...

Another person on this forum ran into the issue that she had been approved for surgery, but at the begining of the year, her insurance would be changing to a new company, and she couldn't get an appointment in time with her surgeon, before the time in which her insurance would change over. So I responded to her post with some suggestions on how to convince her surgeon to get her on the books to have surgery in time...but in that same post I also gave her a long list of things she might try to obtain surgery should she not get on the books to have surgery in time. So I will post that response link here, so you can read those suggestions on alternative ways to get your WLS: http://www.gastricsleeve.com/forum/t...tml#post483736

Now, one of the things that I forgot to suggest in that thread, that might be beneficial to you is a company called the lendingclub .com. I didn't mention it in that other response because I had honestly forgotten about it, until I ran into a financing question on another WLS forum when this company was mentioned. When I asked my fiance if he had ever heard of the company, he started laughing and said "You are not going to believe this"...the lending club business model was based off of an original business model that my fiance had built years ago...the company he built the model for was originally called funding gator.

The basis of this type of funding, and what makes it different, at least in the original business model is that it is P2P (Peer to Peer) lending. The concept to this type of lending is that a group of investor put up minimal amounts of money to fund a number of different things. Where the investors benefit, is that instead of investing large amounts of money into a singular investment that may or may not yield them a return on their investments. The instead are spreading out the investment risks over many projects, utilizing a blanket investment method...so while some may not yield a return, other will, so while the returns on their investments may not be as high, the risks to the money they invest is drastically lowered.

The benefit to the people seeking investment capital is that the money being lent didn't take things like credit scores into account when lending the money. I have not looked into how the lending club may have changed from the original business model developed by my fiance, but the original model, allowed for lower interest rates, since the money being lent came from a large number of different investors. It also was specifically designed with the anticipation that many people might default on their loans...and leverage those statistical probabilities accordingly to protect the investors, and sustain the business model.

I know that maybe these suggestions may not be able to help you, but I hate seeing people lose the chance to have wls. So I wanted to post this information just in case you might find something in what I have written that may be able to help you out. Whether or not these options help, I hope you don't give up on your desire to become healthier, and if you have any questions about something I have written, or options you may find in the future, feel free to contact me and ask questions. I would be happy to help in any way that I can. God bless, I really hope that you are able to find an option that helps you achieve your weight loss goals.

[dmart27]

Have you already tired to get the wls financed? My insurance company denied me. I was approved for financing but declined it because the interest rate was too high. Now I decided to save and put the rest on my credit card. Good luck to you!!!

[ggibbons]

i think your dr might of fail you some how on this, because if u go on the required diet the dr gave u & u couldnt loose wt there is something else wrong so there fore the surg wont help much. for instance a thyroid prob or something.... but since u went on the diet & was able to loose the wt proves u will do great with the surg. what i feel they failed u in is : yes u can loose the wt, : no u cant keep it off with out the surg. now weather u can or cant ur dr should of stated something about how compliant u were on ur diet, & that because u loose ....u gain.....u loose u gain. is the whole reason u need the surg ok, work with ur dr, i bet with in 4 -6 months he will fix it so ur insurance will pay. u just got started sweety. dont quite. i have helped 2 women with the same thing that happened to u. just ell ur dr, u do the diet & u get soooo far & it just stops,, then it starts climbing back, and tell him to do everything he can to help ur ins. to get this done for u . apeal apeal & reapeal. but i bet it wont be long if u need to talk , im hear u will get it. u will see

[ggibbons]

also, write & or call ur ins co. & tell them that if they approve u for the surg it will save them alot of money in the long run , because it may cure u of any health issues u have & prevent u from ever getting health probs related to being over wt. they & ur dr work for u , u pay them to . just keep working girl

[char602]

@ Melanie, I don't think your points are idiotic, but it does bother me that your generalize. I don't know of Journeys personal insurance situation, and it definitely sounds like she is stuck with a shady company, with some pretty unattainable guidelines. It also sounds as though the surgeon and the insurance company are not working in good partnership with each other.

For Employer Sponsored Health Coverage, the plan design depends on what the employer pays for.... Period.

As for the poster the other day (Belle2), you offered some GREAT advice, but the solution for her was that she went back to the company and found out that it IS covered after January.

I worked for an insurance company for 13 years and I know for MANY companies, from a business standpoint, the hoops are their way of weeding out those that won't be successful. Why shouldn't they be able to do that? The same way a lender will only loan you money if they can confirm that you are a good risk. From a cost analysis perspective, VSG costs on average less than the cost of Diabetes Maintenance for the average diabetic for one year.

Again, I think you have good points to a certain degree, but when you generalize, you basically call an entire industry into question. Its also not helpful to the newbies who may be in the early stages of getting insurance approval to make them feel as though the cards are stacked against them.

[char602]

@ Journey, I'm so sorry to hear that this happened to you. It certainly doesn't sound fair. It sounds as though both your insurance and your doctor have failed you by not clearly communicating with each other in terms of guidelines.

[azladyrider]

I read an article many years ago in the Readers Digest that I already followed myself which said to FIGHT every denial. Insurance companies nearly count on people just saying "oh ok thanks anyway". I recently had to fight with mine for a breast recon - I had a mastectomy on the right and the left the implant removed. Original mastectomy was due to chronic infections in 99 so when they approved my recon they denied the other one being done too, they said they only paid for both to be done for symmetrical reasons if cancer was involved. I emailed them one link - the link stated clearly that it is a FEDERAL law that said that both breasts have to be made to be even if the one breast removed for MEDICAL reasons - no mention of cancer. So since mine was for a valid medical reason they approved them both. Even my doctor was shocked - he too thought that he law only covered cancer.

But I guess my question is were you told how much weight you were allowed to lose before surgery to still meet eligibility? Why did they want you to lose any in the first place? I didn't have that issue since my BMI was only 30 so I wasn't on any pre-op diet.

@ Melanie, I don't think your points are idiotic, but it does bother me that your generalize. I don't know of Journeys personal insurance situation, and it definitely sounds like she is stuck with a shady company, with some pretty unattainable guidelines. It also sounds as though the surgeon and the insurance company are not working in good partnership with each other.

For Employer Sponsored Health Coverage, the plan design depends on what the employer pays for.... Period.

As for the poster the other day (Belle2), you offered some GREAT advice, but the solution for her was that she went back to the company and found out that it IS covered after January.

I worked for an insurance company for 13 years and I know for MANY companies, from a business standpoint, the hoops are their way of weeding out those that won't be successful. Why shouldn't they be able to do that? The same way a lender will only loan you money if they can confirm that you are a good risk. From a cost analysis perspective, VSG costs on average less than the cost of Diabetes Maintenance for the average diabetic for one year.

Again, I think you have good points to a certain degree, but when you generalize, you basically call an entire industry into question. Its also not helpful to the newbies who may be in the early stages of getting insurance approval to make them feel as though the cards are stacked against them.

[Journey Tobeme]

I will be calling the Surgeon's office in a bit to see if they can call the insurance company. The insurance company has already denied my appeal. They do not allow you to appeal the denial of the appeal lol. You have to appeal with the State Insurance Board (very costly and lengthy).

My BMI is still over 40. My surgeon requires his patients to lose 10% on their own just to show dedication. My insurance did not say anything about losing weight until the denial. The only thing mentioned was if I lost too much and slipped into their other category because of BMI.

[azladyrider]

Wow so glad I didn't have to mess with the insurance places

[BBCorvette18]

All insurance is bullshit they just want your money.