Denied again!!!! - Page 3 - ThinnerTimes

BabyNicole · 06-05-2008, 08:32 AM

Quote:

Originally Posted by timidcharm

It would seem getting aproval is some what a right of passage. I am on the edge of the bmi limits at 40 BMI and I am having to convince PCP that I need this WLS. Ive been large since I was a child and have Hbp and Cholesterol , and a curvature of the spine . Now the PCP sys try diet and excercise. Hello ....Im 48 yrs old Ive tried them all , Hell Ive been hypnotized . acupuntured,tried shots of who knows what ....Im at my whit's end.

So do I doctor shop ? Or fade away and accept I will always be FAT and accept it ? Im sorry for the rant

What I suggest you do (what I did) is write a list of reasons you feel surgery is necessary for you, what you've tried in the pasted, what research you've been doing, if you've seen a psych and/or NUT, yada yada. Then he'll see how serious you are. Good luck!

doxielover · 06-05-2008, 09:21 AM

If I were you I would find a new PCP as soon as I could. Talk to the surgeon's office and ask them for names of PCP's that are wls friendly. You don't have to give up on this process!

timidcharm · 06-05-2008, 04:00 PM

never surender

SueRN · 06-06-2008, 05:09 AM

What are the requirements of the medical policy for your insurance? Most want to see for the previous 5 years (some don't even include the current year) that you have had a BMI of 40 or more with no co-morbids or 35 and over with at least 1 co-morbid during that you are being treated with medication for the previous 4 of 5 years. Insurance company policies are based on the standards of care that is put forth by the medical profession. For bariatric surgery, it is thought to be used as a last resort after everything else has been tried and failed. It is expected that if people are just below these standards and haven't been obese for at least 5 years, diet and behavior modifications still have a chance to turn it around. In fact, bariatric surgery really is NOT the standard of care...it is a last resort treatment. There are gold standards for the surgery itself. This isn't insurance company policies but the medical profession's guidelines. Again, don't give up. This is all about getting healthy and learning the right way to live and take better care of yourself....not about having surgery. While you are exploring your options, make sure you continue to see your doctor, take your BP medications, get everything that you are doing documented by your doctor and appeal. The worst case senario is that you may have to wait a few years to get the recorded weights that you need. don't hurt yourself by trying to gain weight. just try to maintain what you have. slowly make lifestyle changes that you will have to make anyway once you have the surgery. you will actually be better prepared once you do. hang in there. sue

Native2u · 06-10-2008, 03:19 PM

I found out why Aetna denied me. I talked to a RN at Aetna and she stated that she was a Supervisor of all RN's there. She went through everything with me, including telling me that they haven't received the appeal from my WL insurance person (that should have turned in everything again, highlighted....for the appeal). I was totally in shock over that one!

I went to see my PCP today and informed him that I needed his notes to read a different way, in order for Aetna to approve me. He agree to do it. I supports my WLS 100%. His nurse on the other hand....she isn't too happy with me, more work for her. She also isn't the nicest thing to me and I have been HIS patient for 8-9 yrs now....she is full of attitude.

Godsblessedme · 06-10-2008, 03:34 PM

see! i told you you'd get results with the reviewer RN ! wooohoo well i would personally talk to the pcp not just leaving a message since the nurse there has much "tude" and i would mention that to him too. usually they are just MA's and have no actual nursing experience other than blood press's, injections and such. So i would speak to your doctor. And hoping that the WL insurance person will REDO her work to state your wanting the appeal. it sounds like your making headway

snick1899 · 06-10-2008, 03:58 PM

Awesome! I am so glad to hear you are getting somewhere with them!!

BuCwiLd · 06-10-2008, 04:28 PM

this thread really worries me please review this and tell me what you think...

here is what the surgeon wants.

1. stop smoking 2 months prior to date
2. 5 percent weight loss (they wanted 10 but my disc problem doesnt allow me to exercise)
3. read a book / 10 modules
4.attend 3 educational classes
5.attend 2 support classes
6.metabolism determination (whats that?)
7.psych evaluation
8.rd evaluation with green light (dietitian)

here is what my insurance requires

1.obesity present for more than 5 years, medical documentation needed.
Now it has existed for way more than 5 years but i moved from Ct to pa 3 years ago. I have med doc. from 06 foward but i hadnt seen the doc prior to that since 2003. so i only have 3 years.i called my previous doc and he said he would search for it but honestly they may be gone due to it being more than 5 years ago

2. bmi of more than 39
check- mines is 43

3.history of failed dieting
I dont have that (guess the 6 month program will cover that)

4.current medical evalution
check-i can do that

5-document of a co-morbid medical condition
check-high blood pressure, somewhat high cholesterol .

I do have 3 letters from 3 different surgeons stating that this surgery is nessasary in order to have my back fused or discs replaced..I am currently out of work for more than a year.. Everything in life is pretty much impossible

doxielover · 06-10-2008, 07:17 PM

Buc - I think you will be just fine! Your spine condition is a huge co-morbid. Your PCP needs to write a really detailed letter so the insurance will refer you. Also, letters of medical necessity from your neurosurgeon/spine surgeon will be a huge help. Start rounding up those letters right now and things will go much quicker when it's time to sumbit to the insurance company. Good Luck!

BuCwiLd · 06-11-2008, 01:20 PM

Quote:

Originally Posted by doxielover

Buc - I think you will be just fine! Your spine condition is a huge co-morbid. Your PCP needs to write a really detailed letter so the insurance will refer you. Also, letters of medical necessity from your neurosurgeon/spine surgeon will be a huge help. Start rounding up those letters right now and things will go much quicker when it's time to sumbit to the insurance company. Good Luck!

i did what you said i have 3 letters on the way from 2 sugeons and one back specialists saying that without losing the 100-125 pounds i cannot get the surgery i need for my back in order to return to society as a productive member.. i just started my 6 mnt program, so i hope there is no expiration date. lmao