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Sunday, January 16, 2011

denial update

After spending wayyy too much time on the phone with the insurance company and my bariatric office, I found out why I was denied.

I know you guys see my weight and think I'm "tiny" but I'm not.  I'm only 5 ft 2.  I'm a roly-poly.  Or I was when I started.

1.  My starting BMI was calculated at 37.9---which was wrong for two reasons.  First, my height was incorrectly measured by 1 inch.  Second, they accidentally used a weight from after I lost 8 pounds under their supervision.  DUH.  So, if the math is done correctly, my starting BMI was 39.3.  So I asked the PA at the bariatric office if I could come in and get remeasured for my height (I have two other official measures from outside offices that have me measured legitimately at 62").  I was hoping I could get measured again and my paperwork could get resubmitted with the correct information. The PA said, "Sorry, there's nothing I can do."  What?  Why???

I'm an occupational therapist and when I made errors on insurance claims I fixed them and resubmitted.  Why can't they??!!  I want to know!  I'm seriously considering emailing the surgeon directly.  What do you guys think?

I am not trying to fudge numbers.  I am five foot 2!  This makes a big difference.  Perhaps it was my ponytail that day that caused the measurement error, I don't know.  But I'm not 5 ft 3.

2.  I need to have a BMI of 35-40 plus 2 co-morbidities OR a BMI of 40 to qualify outright.  The doctor at the insurance company who reviewed my chart and denied me said my co-morb of high BP and high cholesterol weren't "serious enough."

Yes, I got a copy of the denial letter and that is what it said.  Word for word!

I'm really frustrated and feel it's unfair.  I did some calculations and if I'd weighed only FOUR POUNDS MORE when I started this process, I would have had a BMI of 40 and would have qualified outright (been fat enough!) and no doctor could have sat behind a desk and judged the "seriousness" of my co-morbidities.  That seems hugely unfair to me!

It was summer time!  I should have worn jeans instead of those super light weight capri pants!  I should have gone in the afternoon instead of morning.  I should have eaten a big gigantic meal.  Or two or three.  And drank a lot of water.  Maybe even have cheated and worn a 5 pound ankle weight to be really really sure.  What the heck??!

But I'm an honest person.  Unfortunately for me.

My PCP is working hard on an appeals letter.  I also have a bladder disease called interstitial cystitis (IC) which she believes contributed to my weight gain because of all of the medicines I take to manage my symptoms and pain of that disease.  I went to see her on Friday and she pulled out journal articles that support her stance that the medicines I need (for the rest of my life) all cause weight gain but are necessary to manage my symptoms and allow me to work and have a life.  (This is a serious & very painful disease.)  She is going to base my appeal on that.  The insurance company feels if my blood pressure were "really serious" I'd have been on "triple therapy" to manage the BP instead of one medication.  She is also going to base the appeal on the fact that I wasn't on "triple therapy" for the high BP because that would aggravate the symptoms of my IC to be on diuretics and whatever else triple therapy entails.  Even when I was on Procardia for my BP, it still wasn't in the optimal range for BP, it was still about 130/85, and wasn't treated further, b/c of the reason I just said.  

I'm hoping it will work.

But I'm getting used to the idea of being a little chubby forever....and trying to learn to love myself as I am.

I'll still working out but.......I know I have an appetite problem that is beyond my control..... and too many calories is too many calories no matter how high quality the food is.

Thanks for listening to me complain and I promise to get off this topic eventually.


  1. Vent on! That's why we're here... Keep on fighting the good fight and standing up for yourself.. We all need to be advocates for our own health and well being.. We're on YOUR side!

  2. Keep fighting!!!! I had to resubmit mine as well and remember how devastated I was when I got my first denial letter. We are here for you and I am praying that you will be approved!

  3. I'm rooting for you. I hate that insurance companies have the ability to make so many arbitrary decisions.

    Keep fighting and hang in there. Try not to let it discourage you.

  4. I am really hoping this all works out, and don't give up. Things are changing every day with the insurance companies and the requirements. keep fighting the fight, and hopefully it'll end well. stupid insurance companies!

  5. sending hugs, so sorry about this disappointment after all of your progress preparing.... I hope the appeal goes through on the first try. Just don't accept "no"- keep asking if there is someone else you can talk to about it... I really am hoping for the best for you.

  6. Wow..I am so sorry to hear all of that. Keep up the fight and I pray that things work they way are suppose to. Keep on venting to us. I feel like I've been complaining alot too, but it's nice to have this support system out there. Most people don't understand...but we all do. So just keep talking to us! Good luck!


  7. Just keep venting! I believe the appeals process will eventually work - especially with such a great advocate of your PCP. I'm 5' 2" as well and the only place I've ever, ever been measured as more is in my band surgeon's office. They insist I'm 5'2 1/2". There's no way I suddenly grew a 1/2" at age 44. Odd that it's the same for you, only a whole inch. That's a big miss.

    Anyway - It's totally amazing that the doctor's office isn't working hard to help you get this fixed - as ultimately it's money in their pocket. I'm sorry you're having to go through all this, but your good attitude and perseverance will ultimately pay off!!

  8. You are being proactive and doing all the right things...can you talk to an administrator in your WLS office? I think the administrator would think differently than the PA. It's not only money in their pocket but it is the right thing to do.

  9. Vent away and definately use what you can from your PCP about your other medication. I was only on a single blood pressure medication, and that as because I am not allowed to have more, thye simply would have to change the drugs...and there are so many I am not allowed. I self paid but honestly this would drive me wild.

    Did the insurance dr not have a full medical history? As I imagine what other medication you are on would give him an indication that there is something else, and if he doesnt understand what medications you are on, perhaps he isnt adequately assessing cases.

    I would insist on getting remeasured as this is completely in adequate, if you lied on your paper work they would have a fit, but if they lie on it, it's ok?

  10. You may have mentioned this already but have you had a sleep study done? My BMI was just over 35 when I started this process and to qualify I had to have a co-morbidity. I didn't have one but my surgeon told me that 65% of people who are just 15% overweight (i think i have these stats right) have some level of sleep apnea. The insurance companies don't look to see 'how bad' the apnea is, they just want to see the box checked next to "apnea". Well, I had a sleep study and I had SLIGHT, VERY SLIGHT apnea but it was enough to get me through the insurance people.

    Insurance covered some of the sleep study b/c my surgeon requested it. I think in the end I paid about $300 for the study. Check into it if you haven't already.