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09-06-2006, 03:05 PM
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#1 (permalink)
| | Newbie
Join Date: Jul 2006 Location: Wisconsin
Posts: 4
Weight Statistics July 2007 Start Date:
July 18, 2007 Surgery Date:
Height:
409 lb Start Weight:
336 lb Current Weight:
200 lb Goal Weight:
73 lb Weight Loss:
136 lb Lb Left to Lose:
17.8484107579 % % Lost:
|  Direct exclusion question
I have United HealthCare (in Wisconsin) and a direct exclusion for WLS. I have a BMI of 62 and severe Osteoarthritis in both knees and on CPAP for sleep apnea. Doc submitted pre-determination to insurance and, of course, was denied.  I have also read Craig Thompsons "WLS Insurance Secrets" e-book. Has anyone EVER been approved when they have a direct exclusion on their policy? 
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09-06-2006, 07:16 PM
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#2 (permalink)
| | Seasoned Veteran
Join Date: Jan 2006 Location: SOMEPLACE LONG ISLAND, NY
Posts: 6,809
Weight Statistics June 1, 2005 Start Date:
5' 5"
Height:
310 lb Start Weight:
167 lb Current Weight:
159 lb Goal Weight:
143 lb Weight Loss:
8 lb Lb Left to Lose:
46.1290322581 % % Lost:
Body Mass Index51.5810650888 BMI Start:
27.7872189349 BMI Current:
26.4560946746 BMI Goal:
Weight Loss MethodRoux en Y Gastric Bypass
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Sorry wish i had something to offer here but i dont.
JUST wanted to offer you a (((HUG)))
and so glad to hear you even tried the ebook
by Craig.
I hope someone has some great news for you on this
stressful issue!
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09-06-2006, 09:37 PM
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#3 (permalink)
| | Big Loser
Join Date: Jun 2006 Location: Massachusetts
Posts: 156
Weight Statistics 7/26/06 Start Date:
10/3/06 Surgery Date:
Height:
314 lb Start Weight:
145 lb Current Weight:
145 lb Goal Weight:
169 lb Weight Loss:
53.821656051 % % Lost:
10/3/07 Goal Date:
Body Mass Index52 BMI Start:
24 BMI Current:
24 BMI Goal:
Weight Loss MethodRoux en Y Gastric Bypass
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I dont have any suggestions on the fact that it was a direct exclusion. I know this is hard for you. Is it possible for you to cancel that insurance and purchase a plan like Blue cross blue shield directly through them. Yes you wont be getting the benefit of having your company chip in and pay for part of your policy but I know for a fact that my plan is a family plan with BCBS and for me to purchase it directly is about 925 a month. It may be worth it in the long run to purchase the insurance directly, If you think about the addl cost of all co pays to see the dr more often and copays on medication you take it may come close to the difference. Yes its more money now out of pocket but after you reach a healthy weight you will come off all excess medication and begin saving money, then you can go back to the old insurance after surgery if need be.
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09-07-2006, 12:35 AM
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#4 (permalink)
| | Seasoned Veteran
Join Date: Mar 2006 Location: NYC ~ Love it!!!
Posts: 3,008
Weight Statistics 4/19/06 Surgery Date:
5' 8"
Height:
333 lb Start Weight:
175 lb Current Weight:
170 lb Goal Weight:
158 lb Weight Loss:
5 lb Lb Left to Lose:
47.4474474474 % % Lost:
someday... Goal Date:
Body Mass Index50.6269463668 BMI Start:
26.6057525952 BMI Current:
25.8455882353 BMI Goal:
Weight Loss MethodRoux en Y Gastric Bypass
|  Mr. Mel....
....I think Jess' oppinion is great...and worth a try... I'm sooo sorry that your insurance has this "exclusion"....wow! I hope you have some luck...this surgery is the best thing!! My BMI was 53...and now, I'm at a BMI of 38 about 1/2 way thru my weight loss. Don't loose hope...do whatever you can!! You won't regret it!! | |
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09-07-2006, 07:29 AM
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#5 (permalink)
| | Seasoned Veteran
Join Date: Jan 2006 Location: SOMEPLACE LONG ISLAND, NY
Posts: 6,809
Weight Statistics June 1, 2005 Start Date:
5' 5"
Height:
310 lb Start Weight:
167 lb Current Weight:
159 lb Goal Weight:
143 lb Weight Loss:
8 lb Lb Left to Lose:
46.1290322581 % % Lost:
Body Mass Index51.5810650888 BMI Start:
27.7872189349 BMI Current:
26.4560946746 BMI Goal:
Weight Loss MethodRoux en Y Gastric Bypass
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I also feel Jess's idea might be well worth the doing!
GOOD LUCK and keep us posted
hugzzzzzzzzz
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09-07-2006, 07:50 AM
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#6 (permalink)
| | Seasoned Veteran
Join Date: May 2006
Posts: 2,109
5/17/06 Start Date:
5' 6"
Height:
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Where are you in WI MM? Some surgons will circumnavigate the exclusion clause by finding another problem to fix, like acid reflux or hernia.
Kat
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Play by the rules, but be ferocious.
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09-07-2006, 08:38 AM
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#7 (permalink)
| | WLS Mentor
Join Date: Aug 2006 Location: Milford Kansas
Posts: 1,205
Weight Statistics 09/01/2006 Start Date:
5' 4"
Height:
254 lb Start Weight:
144 lb Current Weight:
140 lb Goal Weight:
110 lb Weight Loss:
4 lb Lb Left to Lose:
43.3070866142 % % Lost:
02/01/2008 Goal Date:
Body Mass Index43.5942382812 BMI Start:
24.71484375 BMI Current:
24.0283203125 BMI Goal:
Weight Loss MethodRoux en Y Gastric Bypass
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KAT that was a great suggestion. I wish there was something that could be done to prevent insurance companies from excluding WLS when all it does is saves lives and in the long run money for the insurance company. Its just a shame that insurance compaines can't see it.
__________________ Surgery Date 09/01/06
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09-07-2006, 09:17 AM
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#8 (permalink)
| | Newbie
Join Date: Jul 2006 Location: Wisconsin
Posts: 4
Weight Statistics July 2007 Start Date:
July 18, 2007 Surgery Date:
Height:
409 lb Start Weight:
336 lb Current Weight:
200 lb Goal Weight:
73 lb Weight Loss:
136 lb Lb Left to Lose:
17.8484107579 % % Lost:
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I am in Racine, WI., 25 miles south of Milwaukee. I am quickly finding out that the direct exclusion is 'iron clad' and 'carved in stone' and no way around it. I have avoided even looking into WLS for years because I have always believed it should be a LAST resort when all else has failed. I have come to that point and have a peace about it. I found out, a few years ago, that I have a syndrome called "insulin resistance". I am not diabetic but this syndrome messes up your blood sugar when you eat ANY refined grain products, potatoes & sugar etc.etc. A low carb way of eating has helped greatly keeping this under control. I do a modified type Atkins, plan eliminating a lot of the fat. Problem is I can't excercise because of my bad knees and I have to almost starve to lose any weight. I just found out there is some light at the end of the tunnel though. The hospital and doctor I'm seeing about WLS has some pretty big discounts for people that are paying out og pocket. We'll see. The good Lord is in control and hasn't ever let me down.
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09-07-2006, 09:29 AM
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#9 (permalink)
| | Big Loser
Join Date: Jun 2006 Location: Massachusetts
Posts: 156
Weight Statistics 7/26/06 Start Date:
10/3/06 Surgery Date:
Height:
314 lb Start Weight:
145 lb Current Weight:
145 lb Goal Weight:
169 lb Weight Loss:
53.821656051 % % Lost:
10/3/07 Goal Date:
Body Mass Index52 BMI Start:
24 BMI Current:
24 BMI Goal:
Weight Loss MethodRoux en Y Gastric Bypass
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Mr. Mel-
I too am Insulin resistant. Im sure the put you on glucophage or metphormin right? This helps alot with the weight loss. But it has its side effects for some people so try to get extended release type. This brings your insulin resistance levels back to normal with the pills and diet. I lost 20 lbs the first month on it. With out the medication I too felt I was straved. The meds give you less feeling of hunger. The reason im getting WLS is I have a BMI of 50.2 And I am sick of those pills, first they gave me side effects that refused to go away. Just continue to look into your options, If you get a huge discount from the hospital then it may be worth it. Otherwise I would shop around for another insurance plan. WLS will save your life, and Blue cross had no problem approving me. I had my first consult on 7/26 and by 8/2 I had the approval from the insurance company. Good luck and please update us on your progress
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09-07-2006, 09:51 AM
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#10 (permalink)
| | WLS Master Guru
Join Date: Feb 2006 Location: Near St. Louis, MO
Posts: 636
Weight Statistics June 17, 2005 Start Date:
June 17, 2005 Surgery Date:
5' 2"
Height:
313 lb Start Weight:
268 lb Current Weight:
220 lb Goal Weight:
45 lb Weight Loss:
48 lb Lb Left to Lose:
14.3769968051 % % Lost:
July 15, 2010 Goal Date:
Body Mass Index57.2421956296 BMI Start:
49.0124869927 BMI Current:
40.2341311134 BMI Goal:
Weight Loss MethodRoux en Y Gastric Bypass
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Sorry to hear you have an exclusion on your policy. I too ran into the same thing with my policy throught UHC. It is pretty much iron clad for sure. They would not budge for me. Do you have the option of switching insurance though your employer? You may want to check into the different companies that your employer offers. Maybe one of those does not have the exclusion. But what I have learned is the insurance company is not the one that puts the exclusion on your policy, your employer is. You may try writing the company executives and request they give you an exception to the policy. I did but my company would not budge. They told me the surgery is too dangerous but covers malpractice insurance here for a surgeon to perform the surgery.
Keep up the fight and don't give in so easily if you really want it.
__________________ Shelley He who finds diamonds must grapple in mud and mire because diamonds are not found in polished stones. They are made.  | |
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