Denied - ThinnerTimes

ConstructionChick · 01-29-2007, 08:49 AM

So I got my letter this past Friday. You have been DENIED. I bawled for an hour. I wanted this so badly. But I’m a fighter and I shall overcome… right?? … right?? I already called my surgeons patient advocate and am waiting for her to call me back. I just don’t know where to go from here. Have you been denied? What did you do?

The insurance (Great-West Healthcare) said I was denied because I didn’t have a 6 month physician documented weight loss program within the last two years (there was a lot of other information about how said program was to be conducted but that’s the gist of it) I only have 180 days to appeal and a 6 month program will take the complete 180 days … can I re-submit with 5 months under my belt? I guess I have to call my insurance today. That’ll be great fun I’m sure. Pray for me, hope for me, lend me your strength. I’m going to need it! My love to you all thanks for your support so far.

Bypassingme619 · 01-29-2007, 08:54 AM

Consider it done. You are in my prayers. There is a whole lot of us that have been denied here and the key is to stay in the good fight. Find out what it is you need to do and do it. Get all the information you need before you re-submit. Hang in there and see it through. This process will make you stronger. Big Hugs.

rivercanyon · 01-29-2007, 09:01 AM

Sorry to hear your bad news. I can't say I can relate because the experience is different up here in Canada but my thoughts are with you.

You will be able to get lots of advice here of how to proceed next.

Keep up the fight it will be worth it in the end.

LoriAnn925 · 01-29-2007, 09:04 AM

This happened to me as well. Instead of appealing the decision. I started my 6-month program with my PCP. Making sure that I knew exactly what kind of documentation the insurance company needed so that my doc was writing down the right things. When I my 6 months were up, I had my PCP fax the paperwork over to my surgeons office, and had them resubmit. I was approved 2 days after they got the paperwork. My suggestion to you, is to call the insurance company and make sure that is the ONLY reason you were denied. So that when you resubmit you have everything you need.

Rachel · 01-29-2007, 09:04 AM

I will keep you in my thoughts and prayers. I hope that you are able to get the answers you need to find away to get this approved. Have faith and do all that you can! HUGS

ConstructionChick · 01-29-2007, 09:09 AM

this is the exact information from my letter:
1. A weight watchers type program including monthly weigh-ins and nutritional analysis.

2. At least monthly clinical encounters with a healthcare professional who does not perform weight loss surgery.

3. Increased activity/exercise unless contraindicated.

4.Behavioral modification program supervised by a qualified professional to reinforce dietary therapy and increased physical activity

5.AND a weight loss management history that includes pharmacotherapy with physician prescribed weight loss drugs or documentation of why pharmacotherapy was not tried.

coptergirl · 01-29-2007, 09:27 AM

I am so sorry you were denied - you will be in my prayers that you will be directed to the appropriate program and that you will ultimately be approved. Hang in there

lealphachienne · 01-29-2007, 01:31 PM

Do you have any of those things documented somewhere? Insurance companies have guidelines and you do need to follow them exactly to get approved. I was denied the first time around and had to resubmit. I didn't appeal, I had my docotr start the process over again and submitted even more doucmentation to prove I had tried everything.

Also, this is a good time to re-evaluate what you want and how much you're willing to struggle for it. I think the majority of us get denied the first time. My ex did too, and he weighed 454 lbs and had 5 years of documented attempts!

This is serious surgery. There's a lot of potential problems. You will always need to struggle and fight, no matter what weight you are. Getting approved for surgery is just one obstacle. The journey doesn't end or begin with WLS.....

Gina in NY · 01-29-2007, 04:06 PM

Don't lose your mind over this - it is just the beginning. There are almost always obstacles - the true miracle is when there aren't.

So - start whatever it is they are telling you to do. The only thing that looks really crazy on there is the pharmcuticals - never heard of that one before. The insurance company can require you to try drugs that are proved not to work long term?? Hopefully there is a reason you can't take them. Otherwise, just jump through the hoops. 6 months may feel like forever - but it isn't. I spent 9 months losing the 10% I was required to lose.. We do what we have to do. Makes facing the knife that much easier if you've fought hard for it. imho

campusman 1957 · 01-29-2007, 06:38 PM

Quote:

Originally Posted by ConstructionChick

So I got my letter this past Friday. You have been DENIED. I bawled for an hour. I wanted this so badly. But I’m a fighter and I shall overcome… right?? … right?? I already called my surgeons patient advocate and am waiting for her to call me back. I just don’t know where to go from here. Have you been denied? What did you do?

The insurance (Great-West Healthcare) said I was denied because I didn’t have a 6 month physician documented weight loss program within the last two years (there was a lot of other information about how said program was to be conducted but that’s the gist of it) I only have 180 days to appeal and a 6 month program will take the complete 180 days … can I re-submit with 5 months under my belt? I guess I have to call my insurance today. That’ll be great fun I’m sure. Pray for me, hope for me, lend me your strength. I’m going to need it! My love to you all thanks for your support so far.

i was denied 2 weeks before surgery to and my surgeon call the director of the insurance which he has many times and straightend it out i was denied for the same reason as you . your surgeon has to go to bat for you this is very common for the insurance companys to do they figure you will go away dont give up youll be fine fight to the end. scott