So today should be an incredible happy day for me. I called the insurance company this morning for a status to find out that I am APPROVED! However, my husband is still under review. It was a bit of a mix up because after I found out about my approval, I called the surgeon's office to see if they had it and I had to leave a message. When I got home from work, there was a message from her (Teresa) saying that they had denied my husband stating that he didn't have the benefit and of course, that made no sense. So, Teresa explained to the insurance company that they needed to check my account because I was already approved. (To make a long story longer, there was a note placed on my account a month or so ago stating where in our policy WLS was stated to be a benefit because it was so far buried in the policy). So because of that, my hubby's request was "escalated" and is still under review. What we didn't know is that his is being requested as a duedondal switch because of his weight, the surgeon thinks he may have to do it in two parts. Teresa feels that will not be an issue and in looking at our policy it states "MO treatment is covered through gastric bypass surgery or such other methods as ma be recognized by the National Institute of Health as effective for the long term reversal of MO." So, while that tells me he should be fine, I'm am still feeling ready to explode! I want to be happy and rejoice but I can't until I know he is approved as well.

I'm calling them again in half an hour in the hopes that the approval has gone through. Thanks for listening to me freak but I have really not been able to tell anyone yet because of waiting for hubby's approval....hubby does not even know I have been approved.

Okay, so I just called and they have at this point denied the husband, showing the sleeve part is experimental...though it is just part one of two surgeries, the second being the bypass part. The girl said the surgeon's office would have to fax them over showing why the sleeve is medically necessary. Does this make any sense??

Kimbre, hang in there!!

So I just talked to the bariatric program coordinator, who is wonderful. She said she will make this a priority tomorrow with Teresa and if need be they will submit the husband's a different way or do a "peer to peer" which I assume is some kind of call maybe with the insurance company. I suppose I've waited six months, so one more day won't be an issue.

I'm sure I sound like some kind of spastic nutjob and I swear I don't mean to. I just want this so badly,but at the same time, cannot see myself doing it if hubby is not approved. It just wouldn't be fair. Everything just feels so close and yet so far away again.

QUOTE(Kimbre @ Feb 19 2008, 04:17 PM)

So I just talked to the bariatric program coordinator, who is wonderful. She said she will make this a priority tomorrow with Teresa and if need be they will submit the husband's a different way or do a "peer to peer" which I assume is some kind of call maybe with the insurance company. I suppose I've waited six months, so one more day won't be an issue.

I'm sure I sound like some kind of spastic nutjob and I swear I don't mean to. I just want this so badly,but at the same time, cannot see myself doing it if hubby is not approved. It just wouldn't be fair. Everything just feels so close and yet so far away again.

Oh KIMBRE...that is GREAT NEWS!! That YOUR APPROVED that is!! I'm sorry to hear about hubby being denied....but why is it that he has to have DS w/sleeve rather than RNY??

Today your approved and today is my 4 year wls ANNIVERSARY!! woohoo!

Now....if I may give you some advice...In the event that hubby doesnt get approved...DO NOT i repeat DO NOT throw your chance away! Because, with one person getting healthier and cooking and eating differently maybe he will lose at the same time!!

I understand your feelings about not being fair..LIFE ISNT FAIR!! Maybe he ought to look into the LapBand or something..of course i'm not sure of the reasonings...sorry if you already posted that.....it's hard to keep up with EVERYTHING these days!!

GOOD LUCk and again....CONGRATS!! I hope it works out for the both of you.....then together you shall GET HEALTHIER!!

Julie

Kimbre, there are many, many people out there who had to jump through hoops for the insurance company to approve their surgery. It sounds like your surgeon has a great staff that is willing to work with you to get it done. I believe you are in good hands. Hubby will get his approval too! Hang in there and don't worry so much.

Kimbre,
Congratulations on your approval. I hope your hubby will have his soon also.

Don't worry about sounding like a nut job. It's the squeeky wheels who get the oil in this world, so squeek away, but make your squeeks count! Make sure your hub knows why he's being denied and then do some more research to make the insurance company see the "error of their ways!" Surely, there MUST be a way around this.

In the meantime, are you going to go ahead with your surgery? I hope so, because, he'll be okay for awhile longer. You need to go ahead.

Keep hanging in there. It's going to work.

Okay, just to answer a few questions...when we met with our surgeon, he explained that with hubby, there would have to be a few possible plans. Hubby is bigger than I am and carries almost all of it in his stomach, making him a pretty big guy. The doc said that he hoped to be able to do it all laproscopically, but if not, he may have to do it open. When he got in there, there was a chance that it might have to be broken down into two surgeries; doing the sleeve first and then once hubby lost 100lbs, then going back and doing the bypass part of the procedure. What we didn't realize was that when it was submitted to insurance last week, his was submitted as DS. Per the bariatric program coordinator at Hopkins, they can submit it another way and I think that is the plan for today.



In all honesty, I have not even told hubby yet that I have been approved, yet alone that so far he has been denied. The thing is that WLS was his idea first, about a year and a half ago and he actually started the process with a different surgeon. I was so freaked out by the whole thing that he put it on the back burner, until a year later, when it became "my idea" so to speak. In other words, I had finally reached the point that I was considering it and finding a peace with the decision. We then agreed to do this together and support one another. At this moment in time, I cannot imagine going through with this if he can't. That could change, but I can only imagine how I would feel if the tables were reversed; if he was able to get my heart and soul's desire and I couldn't. Yes, I would be happy for him being able to get healthy, but I would definately feel a lot of jealousy as well.

I'm not even really going to deal with any of that thought process yet. I am currently holding onto the belief that my surgeon's office will work all of this out for my husband and that by the end of the week, all of this will be water under the bridge and we'll both be gearing up for our surgeries. It's the only way I can think right now.

Kimbre,
Congratulations on your approval. Hang in there I am sure things will come through for your DH. When it comes to dealing with insurance companies nothing makes sense. And you can sound like a nut job anytime you want. You have to get it out and we've all been through it or are going through it so we can all relate to you distress.
Again, congrats and hang in there.

Congrats on your approval. I am sorry for all the melodrama with hubby getting approved. Hang in there. DO NOT GIVE UP. Both you and hubby need to stay strong! And remember to breathe. My mom always told/ taught me that nothing worthwhile is easy. That is why we appreciate so much more in the end. Keep fighting.

Thinking of you and sending hugs!