Self insured denial

[Misty2Be]

What is the name of your state?What is the name of your state? CA

Hello,
I am attempting to have gastric bypass surgery. When I called my insurance company to find out if it was covered, they said yes as long as it was medically necessary (it is) and I had a bmi of over 40 (I do) and was at least 100 pounds overweight (I am 127 over). Denied twice, claiming it was not medically necessary. I hired an attorney, final denial received yesterday, saying I "don't meet the guidelines" which, from what I can make out of their legal mumbo jumbo, was to have been on a doctor supervised diet at the same time as seeing a nutritionist and being involved in an exercise program WITHIN the last 2 years. Well, the problem I have with this is it's not like I haven't done that 10 zillion times in my 40+years. I lose, gain more, lose, gain more. My health is at risk! Even the NIH guidelines say that I am a good candidate for this surgery.

We are insured through a self insured plan, a PPO. (don't know if I am allowed to state the name of the company but the initials are GW- I hate them) From what I am reading, ERISA is not going to be any help whatsoever.

Any advice?

 

[MellowCat]

You are going to have to provide "G-W" actual copies of records showing you went to the doctor(s) over a (usually) 6-month period. The records should show what diet program(s) you were on, your weigh-in info, etc. Most ins. companies will also take Weight Watcher records and the like. Until you have proven that you have actually attempted doctor-recommended diets without success, they will continue to deny authorizing the procedure. I suggest you get with a doctor or nutritionist and start a program to at least show you've made an attempt. Visits to a doctor once a month over a period of 6 months is usually the requirment, but don't forget to ask G-W how many months of documentation are required (get very detailed specifics from them, or they will be vague). Once you go through that process, then you can furnish them the documentation they require.

I work for a surgeon that offers this procedure, and know that this is a fairly standard requirement with almost all ins. carriers (in addition to meeting the medical criteria, as you do). I don't think an attorney can help you at this point.

Our office has a dedicated program with staff that assists patients with these types of insurance requirements for Gastric surgery. It would be best if you could find a surgeon that offers this type of help in pursuing your surgery, as it can be rather cumbersome. Good luck to you.

 

[Misty2Be]

Thanks

I did have those kinds of proof- only they weren't in "the last 2 years". I've dieted for 30+ years, so I find this to be ridiculous. Oh yea, I just love documenting my failures one more time. NOT. I do have an attorney and they are fighting it. The NIH standard (as well as others) have shown that once you reach morbid obesity, diets don't work.

And another interesting note- the insurance company was saying that, during those previous 2 years, I was not considered "morbidly obese" for most of it. That's because I dieted (not documented though- I had no idea I was going to need documentation) and lost weight, but as usual, did not keep it off. It's so ridiculous. "You haven't dieted with documentation for the past 2 years, and weren't morbidly obese for part of that time, so we're denying you." That makes no sense whatsoever.

 

[MellowCat]

Ok, I think I understand their "logic" now. You were on a diets in the past and weren't morbidly obese, at least part of that time, which shows them that dieting worked for you, to some extent, in the past. They want to establish what could have changed in the last 2 years that would cause dieting to no longer work for you as it apparently once did. You say you can't keep it off. They want to know if you really can't keep it off while dieting, or if the reason you are morbidly obese is because you do not stick to a diet. You're expected to diet perpetually if it works for you; at least that's basically what I think they are getting at.

Insurance companies HATE covering this surgery and will find any twist they can to avoid paying for it. But I can't help but somewhat agree with where they're coming from on this one. Regardless of what the studies say, they are going to make you document recent attempts that, without a doubt, failed. I know you must be frustrated but you also must understand that this is a major, last-resort surgery that will require intense behavior modification after it's done.

You say your attorneys are working on it for you - I'm skeptical they can do anything but drain your bank account, but I hope I'm wrong and you get your surgery covered. It really changes lives.