Insurance denying - Need records I can't come up with

So how are you going to get over this part of the Policy?

If the criterion above has been met, SelectHealth covers the following bariatric surgeries:
• Laparoscopic/open vertical gastric banding
• Laparoscopic/open gastric bypass (Roux-en-Y) with short limb(< 150 cm)
• Laparoscopic adjustable gastric banding
• Laparoscopic/open sleeve gastrectomy
​
Adjustments to the laparoscopic adjustable bands are covered as part of the bariatric surgical benefit
only. Adjustments to the laparoscopic adjustable bands are never covered as part of the medical benefit.

SelectHealth does NOT cover the following bariatric surgeries:
• Biliopancreatic bypass with or without duodenal switch
• (And other procedures)​
 
@Diana, great letter, as usual! And even I knew that the words "constructive denial" were coming.

And also, she wants a sleeve, which is covered in her policy. So that should not be an issue for her.

The saddest part of this whole debacle is that there are lots of other people running into this type of roadblock/intransigence who don't know that this can be fought, wouldn't' know where to begin fighting, can't afford legal representation (or wouldn't realize that it would help) and end up suffering in silence. So, to everyone else, if you know anyone who is trying to get coverage for bariatric surgery and is running into roadblocks, let them know that roadblocks and denials can be fought, and that there is help available. Sometimes all that is needed is a little direction, sometimes just help interpreting a policy, sometimes something more, as in this instance.
 
Just in case you are sayng to yourself, "But I WORK for these people"...

Suze Orman sued her employer, and won, and because she had sued them, they could not fire her.

(And...some old bitch you "know" from the internet filed, with the Dept of Justice, an ADA complaint against her employer, after which she got the accommodation she had requested to begin with AND she became pretty much bulletproof in terms of continued employment...in fact, her immediate supervisor got demoted. "Coincidence?" you ask. The old bitch thinks not.)
 
OH. MY. GOD!!! You guys are amazing! I may not need to go home and take a X*nax to calm down after this day of fighting!
Should I add that letter from Diana to my already written letter I posted or just send the one you wrote?

And I'm totally fine with working with these people and pissing them off. I'm already pretty 'bulletproof' thank goodness. :sneaky:
 
And yes, I'm having the Sleeve... However, Because #1 my insurance doesn't cover it and #2 because my Dr (Cottam) only does the SADI.
 
jas84047 said:
OH. MY. GOD!!! You guys are amazing! I may not need to go home and take a X*nax to calm down after this day of fighting!
Should I add that letter from Diana to my already written letter I posted or just send the one you wrote?

And I'm totally fine with working with these people and pissing them off. I'm already pretty 'bulletproof' thank goodness. :sneaky:
Click to expand...


Use Diana's IN PLACE OF your letter. The legal dept doesn't care if you and your doctor get along...they only care if you have left them a reason to deny the procedure...Diana did not.
 
And let me say this - if the only reason you are not getting a DS (i.e., are willing to fight for the DS) is because Cottam only does the SADI, you should consider the following:
  • Is the VSG going to be enough for you?
  • Have you asked Cottam if he would do a proper DS if you insisted on it?
  • If he refuses, why not go somewhere else?
YOU are the customer - YOU get to decide which surgery is right for you.
 
The reason I'm not doing the DS is because my insurance will not cover it and will also deny anything related after. It's not something I can financially afford without my insurance. As it stands I already have to pay about $6000 for my portion after insurance.
I have asked Cottam if he'd do a real DS but he stated he is only doing the SADI now. I would go elsewhere (Rocky Mountain) for a DS if my insurance allowed it. I talked with a friend at my insurance appeals department and they have never approved (even after appeals) a DS. I believe the Sleeve will be a great tool for me though and I anticipate it working well.
 
Haven't heard back from my insurance case manager yet although I know she has read the email. Feeling very anxious...:cautious:

Got a horrible email back from my surgeon's office "insurance specialist" (because she is far from a specialist)... She started it off with,
"First of all please do not yell at me or threaten me, that is not a good way to proceed through this process. I know you are frustrated and upset, I agree with you, but we/me are not the bad guys here. This is coming straight from your insurance company. According to what records I have you do meet the criteria that is why I sent it on to your insurance."
I haven't actually talked to her just left voicemails and emailed because she never calls me back. I never 'yelled' or threatened her or the surgeons office, I only explained my frustration and mentioned the possibility of getting an attorney to help with the case/appeal. I replied back (because again she doesn't take phone calls) and explained I didn't mean to come across threatening or yelling but now I'm worried my whole surgery is at risk.
Feeling really down. :frown:
 
jas84047 said:
Haven't heard back from my insurance case manager yet although I know she has read the email. Feeling very anxious...:cautious:

Got a horrible email back from my surgeon's office "insurance specialist" (because she is far from a specialist)... She started it off with,
"First of all please do not yell at me or threaten me, that is not a good way to proceed through this process. I know you are frustrated and upset, I agree with you, but we/me are not the bad guys here. This is coming straight from your insurance company. According to what records I have you do meet the criteria that is why I sent it on to your insurance."
I haven't actually talked to her just left voicemails and emailed because she never calls me back. I never 'yelled' or threatened her or the surgeons office, I only explained my frustration and mentioned the possibility of getting an attorney to help with the case/appeal. I replied back (because again she doesn't take phone calls) and explained I didn't mean to come across threatening or yelling but now I'm worried my whole surgery is at risk.
Feeling really down. :frown:
Click to expand...
I found that sometimes getting a faster response means adding your surgeon to the CC list so he knows what is going on in his office.
 
I would call the case manager after lunch, and start the conversation with the following: "I want to speak to your manager. Now." And when she tries to engage with you in further conversation, repeat "I want to speak to your manager, NOW."

And if she refuses to transfer your call, the next call is to your company's legal department, telling them that their preauthorization department is subjecting them to liability for a claim of bad faith denial of coverage.
 
OMG, OMG, OMG, That is just UNREAL!!!!!!!!!! SIMPLY AMAZING!!! My girls had them shakin in their boots!!!!! I am SOOOOOOOO happy for you! I will give Diana a REALLY, REALLY BIG HUG!!!! for you, (which I planned to do anyway) :sneaky: when I see her in person SIX weeks from know!!!!!!!!!!!!!
 

Similar threads

J
Aetna HMO IOQ Denial
2 3
Replies
30
Views
1K
hkj324
hkj324
Spiky Bugger
How about a non-bariatric procedure insurance question?
Replies
4
Views
407
southernlady
southernlady
Spiky Bugger
I think MrSue’s sister is gonna die too soon.
Replies
10
Views
252
hilary1617
hilary1617
Mantecawife
Hi Ladies and Gents!
Replies
13
Views
582
ShrinkingMyTiara
ShrinkingMyTiara
southernlady
13 years ago today
Replies
8
Views
303
hilary1617
hilary1617

Latest posts

Back
Top