Hello everyone, my name is Deejay and I'm a 28yr old mom to triplets. I have struggled with my weight since I can remember and I've been desperately trying to get WLS for over a year now. My insurance company claims its a covered benefit but has put me through the wringer for months now and then finally after having nothing left for them to ask for because I provided everything they wanted, they denied me. I currently have an attorney preparing my appeal and was wondering if anyone else here has gone through this process and had success? I'm so excited to find a support group for this as the local one I belong to is very small and very cliquish, you get no replies unless your part of the "gang" ya know?
Anyway, thanks for any help in advance and I really look forward to getting to know you all.
Thanks.
deejay.. glad to see you. no. make that GREAT to see you!!!
not sure about the appeal process, except that it's real important that you do it. which insurance company is it? what was the basis for the denial? from what i've heard, addressing that is KEY to getting what you want. and so is going directly to the president of the company...
sooo keep us posted. we'll help anyway we can. even if it's just cheering you on.
and those babies are SCRUMPTIOUS!!!!!! they must be a real handful, though!!! how do you manage????
Hi Jiffypop! Thanks for your reply. The insurance company is Cigna and the reason they gave for denial was that none of co-morbidity treatments are failing therefore the surgery is not medically necessary. My attorney says that is groundless and they have great success for getting that kind of denial turned around. I have a bmi of 46, GERD caused from a moderate hiatal hernia, high blood pressure, high cholesterol, joint pain, urinary incontinence, the list goes on. I just don't see how they can say its not medically necessary ya know? My attorney will appeal until they can't anymore which includes going as far as a hearing, so I hope all works out. I've been praying and praying.
Anyway, thanks for the compliment about my kiddos! They are definitely a handful, but such great kids, I couldn't be happier with them. Along with all my weight problems I also suffer from infertility and it took us 6yrs and going throuh in-vitro fert. to get pg and hit the jackpot thank goodness, so they are well worth it to me. Being overweight and taking care of triplets is quite the challenge which is some of the reason I want this surgery. Its exhausting. Thanks so much for the warm welcome, I really appreciate and I'll definitely keep you all updated on the progress!
Deejay Welcome aboard. You will find that no one here is clickish. We all "talk" and you can learn lots. I don't have much info on the insurance coverage, but I am proud of you fighting it. Several companies seem to think it is not medically necessary, If they look at the long range, you will be in better health soon after, and you will lessen your other health risk. In the long run, this surgery could save them money in the future.
Good Luck, and I agree with Jiff, those three are cuties ! I can imagine what a handful they are! Good luck and keep us posted
deejay... someone else around here had trouble with cigna, but i can't remember who!!! don't worry... she'll show up and tell you her story.
as for the comorbidity thing... harumph. the FDA and other federal agencies say that wls is appropriate for people with BMIs of 40 or higher, or for people with BMIs of 38-40 who have certain comorbidities. for people with BMIs over 40, no comorbidities are necessary, although some insurance companies [like cigna, i guess] want to see some just to send us over the edge and try our patience.
are you sure that the gerd is related to your hernia? many overweight people have gerd and no hernia. and hernias are not obesity related. the joint pain = osteoarthritis = generally acceptable comorbidity. not sure if the incontinence does, and i'm not sure about the high cholesterol either.
but you have at least one, possibly two of the usually acceptable comorbidities and you're BMI is high enough that you shouldn't need them anyway!!! any sleep apnea?? <GEEZZZZ.. this is not something i'd wish on anyone, and here i sit, sort of hoping you have it to make this a slam dunk!!!!!>
sounds like your lawyer knows what's what, but it's a shame that you have to go through with this.
Thanks Jiffypop! The GERD they said is related to the hernia, but the surgery would correct it. They can't do the hernia surgery if I'm getting gastric bypass and vice versa, so the gastric bypass would kill 2 birds with one stone. I just wish they could see that. I don't have sleep apnea that I'm aware of. But like you said the bmi and the others should be enough. I'm in the waiting game right now for my appeal to be processed by my attorney, so I'll keep you all updated. Thanks so much for the warm welcome!
Lots of luck, surely you can beat this. Some inusrance companies deny anything that is sent in for pre-approval if it's not a life & death matter. And the fact that it will keep you healthy later on doesn't matter to them at all because according to statistics, by the time these things will be aproblem, you will have changed insurance companies and it will be someone else's problem. But if you keep after them, and I'm sure having a lawyer involved will surely get you some results. Before we started our company, I worked in the billing office for a group of doctors, and worked appealing denials, so I know a lot of their games.
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