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Post by Deleted on Dec 19, 2011 17:07:22 GMT -5
Jeremy is spouting his ignorant and INCORRECT insurance information - will someone please tell him he is WRONG, and tell the OP the correct insurance information can be found HERE? www.obesityhelp.com/forums/ds/4482971/Insurance-Denial/GAAHH!!!: "Most plans I've seen actually require a BMI of 45 with no co-morbidities or 40 with at least two." WRONG! The NIH guidelines apply pretty much universally!"Carrying some extra change or wearing some heavier clothes would add some weight, or you could purposely shrink a little when they take your height - either one would likely get you over the magic threshold of 40." FRAUD!"I would think GERD might qualify as a co-morbidity" WRONG!"I think you're going to have to play the insurance company's games (abide by their rules) if you want this covered." WRONG - she's in CA! |
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Post by Deleted on Dec 19, 2011 18:15:05 GMT -5
Posted this to the OP. This website recently got many of the most dedicated "pay-it-forward" WLS veterans angry, and we have started a new board. Please join us at weightlosssurgery.proboards.com to get input from happy, healthy and successful WLS veterans regarding information you NEED to know before you make one of the most important decisions in your life. This site is beholden to commercial interests - ours is not. |
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Post by Deleted on Dec 19, 2011 18:15:46 GMT -5
Jeremy is spouting his ignorant and INCORRECT insurance information - will someone please tell him he is WRONG, and tell the OP the correct insurance information can be found HERE? www.obesityhelp.com/forums/ds/4482971/Insurance-Denial/GAAHH!!!: "Most plans I've seen actually require a BMI of 45 with no co-morbidities or 40 with at least two." WRONG! The NIH guidelines apply pretty much universally!"Carrying some extra change or wearing some heavier clothes would add some weight, or you could purposely shrink a little when they take your height - either one would likely get you over the magic threshold of 40." FRAUD!"I would think GERD might qualify as a co-morbidity" WRONG!"I think you're going to have to play the insurance company's games (abide by their rules) if you want this covered." WRONG - she's in CA!I PMed her with this info and invited her over here to talk to you.  |
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Post by Deleted on Dec 19, 2011 18:16:44 GMT -5
Opps!!
My reply is in with the quote. Crap!
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Post by Deleted on Dec 19, 2011 20:17:04 GMT -5
Oh boy. . .
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Post by ynona74 on Dec 20, 2011 18:08:02 GMT -5
Good afternoon... I am the person who Jeremy was telling to commit Fraud.
I have been looking for you because you are apparently the insurance guru. Please help me through this! My name is Wynona Heck and I am in Lakewood, CA.
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Post by Deleted on Dec 20, 2011 19:16:06 GMT -5
Good afternoon... I am the person who Jeremy was telling to commit Fraud. I have been looking for you because you are apparently the insurance guru. Please help me through this! My name is Wynona Heck and I am in Lakewood, CA. Welcome!! Glad you recognized that BS for what it was. |
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Post by Deleted on Dec 20, 2011 20:41:18 GMT -5
Good afternoon... I am the person who Jeremy was telling to commit Fraud. I have been looking for you because you are apparently the insurance guru. Please help me through this! My name is Wynona Heck and I am in Lakewood, CA. Your OH post: Good morning everyone...I was wondering how I can get insurance coverage for the DS procedure? I have been denied entry into the program by my insurance company twice. Even though my BMI is 39.9 They say I have to have a BMI of 40 or a comorbidity on their list. I have low back pain, and just recently got diagnosed with GERD. These of course are not on their list. Also once I eventually get into their program, I have to be on a diet and excersise plan that is doctor supervised for one year. How do I get around all this so that I can stop having pain and start living again. Who is your insurance company? Is it a fully-funded or self-funded plan? First: have your doctor round up (see below). Second: get tested for sleep apnea - GERD is not a significant comorbidity, and neither is back pain. Diet and exercise for a year? Not appropriate. Ask for a waiver of the requirement, citing the following documents: www.dmhc.ca.gov/aboutTheDMHC/org/boards/cap/BariatricREV.pdfs3.amazonaws.com/publicASMBS/GuidelinesStatements/PositionStatement/ASMBS%20Position%20Statement%20on%20Preoperative%20Supervised%20Weight%20Loss%20Requirements.pdfYou need to file an appeal of the denial and you should simultaneously request waiver of the pre-op diet requirements; then another to exhaust internal appeals, then she will request the DMHC for Independent Medical Review (IMR). Should take about 2-3 months. From the DMHC IMR Decisions database - all within the last 2 years - the DMHC sure thinks the number is 35: MN11-11918 A 41-year-old male enrollee has requested bariatric surgery for treatment of his obesity. Findings: The physician reviewer found that this patient has a BMI of 38.3 and hypertension, a significant co-morbidity. In addition, he has failed multiple weight loss attempts. Thus, it appears the patient has clinically severe obesity along with a significant co-morbidity and meets National Institutes of Health criteria for weight loss surgery. Therefore, the requested procedure is medically necessary for treatment of the patient’s medical condition. MN10-11813 Choi and colleagues applied the standards from the NIH, which recommend bariatric surgery for patients with a BMI of greater than 40 or greater than 35 with significant co-morbidities. The authors observed positive health outcomes in patients with a BMI between 30 and 35 with conditions such as hypertension, diabetes, GERD, and obstructive sleep apnea. Given that this patient has a BMI over the recommendation for bariatric surgery and has significant co-morbid conditions including hypertension, sleep apnea and GERD, the requested surgery has been established to be medically necessary for management of his health issues. EI10-11545 Weight reduction surgery is indicated for patients with a BMI greater than 40, or a BMI greater than 35 with significant medical co-morbidities. As defined by the American Society of Metabolic and Bariatric Surgery (ASMBS) guidelines such co-morbid conditions include coronary disease, hypertension, respiratory issues, arthritis, and metabolic diseases including diabetes or hyperlipidemia.MN10-11528 (They even rounded her up!) The physician reviewer found that this patient had documented a BMI greater than 35 last year with a weight of 206 pounds and with a BMI of 34.7 thereafter (2 pounds away from a BMI of 35). She also had significant co-morbid conditions including hypertension and secondary cardiovascular disease. The patient had failed prior dietary efforts, completed a multidisciplinary evaluation and was determined to be an appropriate candidate for bariatric surgery. The submitted evidence demonstrates the patient had clinically severe obesity and her BMI rounded to 35, which was the number used by the surgeon and evaluation team to determine her appropriateness for weight loss surgery. |
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Post by ynona74 on Dec 21, 2011 9:44:44 GMT -5
Good morning... I have United Healthcare, I have a PPO I think. I can choose my doctor and don't have to wait for referals. I will do everything you suggested. Hopefully it works.
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Post by lyndiain on Dec 21, 2011 18:58:32 GMT -5
Good luck, Wynona! Glad you found us here, and I know Diana will give you some good advice. I had to fight my insurance company for almost 2 years before they finally caved and paid for my revision to the DS. It is so worth the fight and don't give up! That's what they are counting on... that you'll just get tired of fighting. Best wishes!!
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Post by ynona74 on Dec 27, 2011 12:17:55 GMT -5
Well today I see my PCP for a sleep apnea study referal. Thanks everyone for the best wishes and support.
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