[Exhorter]

Hey Everyone,

It's me still playing the waiting game, only some things have changed. (men cover your ears or don't read.) But I will be turning 50 this month and have not had a period in over a year and a half. Well two months ago I started to spot just a tad so I called my dr. She said keep and eye on it and if you start to bleed heavy or hurt call. Well it passed. Then this weekend it hit me again and I started to bleed and hurt bad. Like I use to when I had periods before menopause. So I call my dr and they now want a pelvic ultrasound done on me. So that is scheduled for next Monday .

Here is the thing now with my insurance ......yesterday my insurance company called my primary dr and began to ask ? about me like what are her problems does she have high blood pressure and any sleep disordered. What has been her past 5 years history of medical supervised weight care? The nurse told her that I have not been a patient of theirs for that long but that I should have that info sent in my the surgeons office.
The nusre said I told her what I knew and I told her you needed this surgery and what was the hold up. Then the insurance company said well we need more info from you about her problems so that we can determine if she really needs this surgery. The nurse told her I am telling you she needs this surgery. So then then my pprimary dr nurse calls me back and said that now she is waiting to hear back from the nurse who is actually assigned to my case, because the one who called here did not have a clue what she was doing and told her that she was just as confused about why she was calling as my nurse was. That is when my nurse said have the nurse from United Health Care who is assigned to her case call me and get this mess straight because this women needs this surgery!

My question is this..... dose the insurance company normall
call your primary dr to get this info AGAIN since it has been sent to them by the surgeons office?
The nurse told the lady from UHC that all the info had been sent and there should be plenty of info for them to see I need the surgery. But then she ask me if my surgeon did a sleep study on me because I was probably going to need that according to that lady to see if I have it. How much does that sucker cost without insurance cause my insurance does not cover it yet or the pelvic ultersound I need done because my $2,500 deductable had not been met yet.


Man this is a mess I now I am really concerned that they are going to turn me down cause it seems they are digging and the right hand has no clue what the left hand is doing.

Then on top of all this mess I now am concerned that something is going on in my female organs due to the bleeding and pain.

HELP

[DianeB]

Oh ((((HUGS)))))) to you. I'm sure all of this is so frustrating for you. My primary doctor faxed over a letter to my surgeon stating my history the past 17 yrs. I do believe this is normal procedure but then what's normal to one may not be to another. I did have to have the sleep disorder testing done. I am so sorry for the female problems your having--just when you think you're out of the woods it starts up again. I'll be keeping you in my prayers that the female problem clears up and that you get a smooth sailing notice on the other--good luck sweetie. DianeB

[MsVickie]

OK now breathe.......... Its normal. First Im gonna tell you why and why I know its normal.

They can send in all the records they want. They will still call and ask questions. What they are trying to get is what it is that they have to have to meet the criteria for that particular insurance.

They are all different. TRUST ME !

The insurance company has everything they need unless they ask for certain test to be done. But they don't look through the records. Funny huh.

Now..... mine was a pretty easy shot as long as I met the criteria. I found out what the criteria was then made sure I had it before even seeing a surgeon. However they still called wanting a recent TSH level and a
H pylori. The TSH is the thyroid stimulating hormone. AKA (they wanted to see if my thyroid was functioning right if not was I medicated for it. )Just so happened my PCP had did one the same day I seen my surgeon. I do have thyroid problems just recently diagnosed even though they check me for it every 3 months.

The H pylori is to see if you have a ulcer. ( They seem to think now its cause by an infection than stress) I had the lab in my office take the blood and have it tested. Then once I got those results I faxed them to my surgeons office with a letter telling them to be sure to fax to TRICARE ASAP.

Even though the surgeons office knows what to send them... sometimes they will just ask for more testing.

This is a constant thing I go through were I work for much less serious operations.

I fax records and they still will call me asking the same thing I have sent in.


Your PCP did refer you right? He would have sent what was needed in Im sure.

I do know that most of them will require at least a 5 year medical history on you. If your current PCP dint have 5 years worth call your old one and have them send the records to the surgeon. Then tell them to send to your insurance company.

What ever that insurance company requires give it to them. You may even think about pulling your hair out, and probably will before its over. Buts its part of the course.

My surgeons office told me up front, The day you walk in my office and I agree you need to have this surgery its at least 2 1/2 to 3 months before its actually performed. If the insurance gets in the way tact on at least another month.

And honey this goes to show you your file never made it to the Medical Directors desk. The nurse has to have all the information answered before its sent to him/her. They will need this information ASAP or they will pend it for further review after they get what they need. I really don't think they will make you do a sleep study. If they do.... Here in Virgina the cost is $2,100. The reason I know that is I do this daily. Its actually a good thing to have if they require it. I have noticed I think in Friendly;s AKA Lisa's post she didn't get diagnosed with it until after she was coming out of the surgery and had a hard time waking up and breathing or sleeping.

This is a easy test. You go in. You get a room like a hotel room and you sleep.

Honey, this is just a part of what you have to go through. Unfortunately your insurance will require allot of stuff to be done. The nurse will cover herself with the criteria. The Medical director don't have to cover nothing. Just what he thinks. Im sure once it gets to his desk you will have no problem.

Its so hard not to be consumed by this. In your heart you know that you need this done. Your Dr's know you need this done. It will work out. And listen.....you have the benefit for this. Your already 75 percent luckier than allot. Many insurance company's are not paying for this any longer. And listen...... if our get a denial...... that is nothing. They have to physically write down why they denied it. Then that is your ammunition to get that part taken care and push it back at them.

I truly believe you will have this approved the first time.

And smile today how about it? LOL if i cant make you smile or feel better go read Ashley's post. She is a nut and always makes me feel better. You take care my friend and let me know if you need my help on this any further. You will be approved.....

[MsVickie]

Opps on the woman issue, Honey I had mine taken from me when I was just 29 so I cant address that. Just do as your Doc asks and get it checked.

[Exhorter]

Ok I sent my surgeon all of the medical records there were so many of them that they had a seperate file for my records. They said they went through all the file and sent the insurance company 15 pages of the most important things about my health in the past 10 years. My weights were on all of those pages, and of course they never were the same because I would lose and then regain.

I have had the H plori test and it was negitive. I sent them everything that they ask me to send them except a 5 yr medical supervised diet plan. The reason I did not have that is because I had no insurance and could not go to the dr. But as I said I do have many things that state I need this surgery. My primary dr wrote the letter, my surgeon wrote a letter, and even my cyropractor (sp) wrote them one stating I had been his patient for over 9 years and he has seen my battle with the weight. So I really do not know what I have not sent to them that they need. The only thing they can turn me down for is that I did not have a dr for 5 yrs to supervise me. But there are still records if they will look!!!!

And what really ticks me off is they have been feeding me lie after lie telling me it was turned over to the medical director. .

[MsVickie]

They should have what they need then. If at any time they documented they spoke with you about your weight that should count. Keep ya chin up hon. Its gonna happen. Have a good day honey.

[fr1endly2]

HANG in there and my fingers and toes are crossed in hopes
you get a speedy approval!
ITS nerve racking!!!!!
(((HUG))))

[DocSanae]

(((((HUGS)))))
I am keeping my fingers crossed for you that your female problem is nothing more than a glitch that some seem to go through.
I am also keeping my fingers crossed for you that your insurance mess gets straightened out soon.

[armywife2aerial]

Im not shore what United Health care you have but my husband and I have it throught the empire plan and I was ready to pull my hair out with this insurace stuff and i called them and asked them what the criteria for bariatric surgery was.

this is what they told me

The requirements to meet the criteria for bariatric surgery
The empire plan united health care

1 BMI 40 or greater
2 Diets
3 exercise programs
4 medications
5 what has or has not worked in the past
6 advise provider of the predetermination request form
7 CODE CPT 7 bills under price of procedure
8 medical necessity
9 medical review ( could take up to 30 days

* once approved good for 6 months


** this is for the EMPIRE PLAN UNITED HEALTH CARE if you do not have it through them it may be different.

** also when you call the insurace you have to talk in there language or you dont get any ware mite as well bang you head on a wall

i hope this mite help a little

[MsVickie]

Good job Ashley. This is a good thing you wrote out for her. There are different health plans under UHC. This should be able to help her alot.