I Need Help!!! - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

leeleerema · 09-18-2004, 12:10 AM

Okay I need some help. I dont know what to do. This is my first time here my sister found this site for me. Ok here it is I'm 40years young and I weigh 235 to 240lbs

,I'm 5'4in tall. I'm on State assistance and I have tried all sorts of diets and cant seem to lose the weight. My Doc said I was a good canidate for the surgery. BUT the state said NO. I dont even know if I can have the surgery because in 2000 I had a hyadal hernia(not sure of spelling) fixed and they messed up my stomach. So i dont know where to go now or what to do!!! Any suggestions will help. Thanx

Phebius · 09-18-2004, 09:17 AM

Lee...did your PCP refer you for the surgery? Did the State assistance program deny you based on that or did you call them and they said they don't cover WLS?

I have an HMO (Blue Shield of California) that was a little tough to get through, but eventually I won. However, I have seen other people write about this because Medi-Cal or Medi-Care doesn't cover this procedure. I would suggest trying to enroll in another insurance program but keep your State assistance. For example, my mother has HealthNet and Medi-Cal and what HealthNet doesn't "pick up", it gets processed through Medi-Cal.

I don't know your situation, financial or otherwise, so I don't know if you can afford to pay for regular insurance coverage, but the best bet is to make sure that your PCP is making the request for WLS, and be persistant.

Just some information for you, most insurance companies are making their patients go through a 6 month "supervised" (Opti-Fast, Jenny Craig, Weight Watchers, etc.) diet plan before they approve the WLS anyway. If you really want this surgery, start one of those now (if you haven't) and make sure your PCP is doing the requesting to the insurance company for the WLS.

Well, I hope this helps a little. Good luck to you on your journey of becoming a "loser".

Take Care,
Pamela
Open 08/26/03
272/138/120

leeleerema · 09-18-2004, 11:44 PM

Im just starting my own buisness and cant afford private Ins now. I asked my doctor about the surgery, and he was the one who put the paper work thru and I was denied, I cant afford Jenny Craig, or any type of Diet program that i have to pay for. I'm trying to get off wellfair, and have no extra money. I have tried all difforent types of Diets. Medi-Cal said i need to go through there Diet Management Program. Is that the 6 month program you talked about? I dont think I know what Opti-Fast is? But thank you for the info. I really really want/need this.

Thanks again
Lee

Phebius · 09-19-2004, 02:00 AM

Lee...since your PCP did put in the request and you were denied, I think you should appeal it. Have you tried that? The first time I tried for the surgery I was denied, but let it go. The second time I was denied, I appealed and won. I did have a year and a half of Jenny Craig, my appeal letter, and my respresentative from my insurance company is what got me approved.

Follow the appeal procedures for Medi-Cal and go for it. Insurance companies love to collect your premiums, but never want to pay for anything. I realize that you don't have an insurance company per say, but I would definitely start the appeal process if you haven't already. You have absolutely nothing to lose, and you have the right to appeal.

No matter what health coverage you have, they are going to make you jump through their hoops, and unfortunately you're going to have to play their game. Most of us here have.

I can definitely understand the financial dilema you're in...Jenny Craig cost me thousands of dollars, but kudos to you for starting your own business. If Medi-Cal said you need to go through their Diet Managment Program, then start it. I'm not real familiar with how the welfare system works, but it's just one of their hoops, so start jumping, and I don't mean that in a bad way...it's just part of the game.

Opti-Fast is just a medically supervised program and it's basically a liquid diet. If your PCP is totally supportive of the WLS in general, he may be able to say that he has been medically supervising your weight loss, and submit another referral/request. Whether that is sufficient or not for Medi-Cal, I'm not sure.

I'm not sure if this will help, but it's definitely worth a shot...a lot of people here have been denied, but have appealed and won.

I know the procedures and dealing with any health insurance company can be overwhelming, but don't give up if it's something you really want or need. It's all about persistance and I'm sure just about everyone here can attest to that. It can be a very long process, it took me just about a year from finally being approved for the consult to the actual surgery. Things are moving more quickly now, but several people in this forum have hit many road blocks so you're definitely not alone.

Well, I hope this can help you somewhat. I am grateful everyday for being able to have this surgery and I'm sure your day will come too, just hang in there.

Take Care,
Pamela
Open 08/26/03
272/138/120

leeleerema · 09-19-2004, 02:42 AM

Thank you so much Pamela,
I will start the appeal process on monday. Make some calls, and do what I can.
Thank you so much
Lee

Phebius · 09-19-2004, 03:07 AM

You are more than welcome Lee. You sounded much more confident and happy in your last response.

If you need any help writing an appeal letter or need some feedback on one, I'm here for you. I wish I could offer you a copy of my old one, but it was in my old computer and that crashed. I'm a pretty good writer and I proof read letters for my VP all the time so I have a lot of experience with that should you need any help that way.

Feel free to email me privately at Phebius@aol.com if you want any feedback on an appeal letter. I know what this surgery can do to change your life, physically and emotionally so I'm here for you. I have always believed in getting what you want, and have always strived for those things in my life. So I offer you the same belief and strength for your journey.

Take Care,
Pamela
Open 08/26/03
272/138/120

watergirl · 09-19-2004, 08:01 AM

Lee, I'm sorry to hear of your hassles. Pamela, great support! You Rock!

I do have two appeal letters. One I can send to you e-mail the other one is quite long with charts and graphs. You can e-mail me privately and I'd be happy to send the one to you, maybe fax/mail the other one?

Lee, I'm cheering you on. God Speed!

lealphachienne · 09-19-2004, 02:18 PM

Also, it helps if you see your PCP monthly and have him/her document every complaint, your diet, your exercise routine, and weight. That also provides a paper trail, along with whatever program you need to do. Document well any co-morbidities, as at your ht/wt, your BMI is barely over 40. Many insurance companies deny on that one number alone if you don't have proof of obesity related diseases. I was a "lightweight" prior @ 5'3", my co-morbidities were hypertension and sleep apnea. I was at risk of stroking out at any moment!

leeleerema · 09-20-2004, 12:10 AM

Thank you Kim and Marie, for all your support and yes kim that would be great you can send it to leecheenut@juno.com and i will start seeing my doc about the info i need to start the paper trail.
Thank you all so much
Lee

watergirl · 09-20-2004, 08:09 AM

The letter is on my computer at home. I'll send it to you tonight. Again, best of luck and be persistant.