Wednesday, January 28, 2009

Official denial letter arrives amidst Ambien CR withdrawal

My official hard copy of the denial letter arrived from insurance today. Basically, I meet all of their medical necessity criteria, except the six months of supervised diet and exercise, which I knew--and apparently, that is their sticking point.

Their criteria for deeming bariatric surgery medically necessary is as follows:

Age 18 years or older;

Body mass index (BMI) of 40 or greater or a BMI of 35-39.9 with at least one co-morbidity including but not limited to cardiovascular disease, type II diabetes, hypertension, coronary artery disease, or pulmonary hypertension;

Active participation within last two years in one physician-supervised weight-management program for a minimum of six months without significant gaps that includes monthly documentation of the following: weight; current dietary program; exercise program.

Recent evaluation by a multidisciplinary team including all of the following:

A recommendation for surgery for treatment of morbid obesity by a bariatric surgeon;

A separate medical evaluation recommending bariatric surgery;

Clearance for surgery by a mental health provider;

Nutritional evaluation by a physician or registered dietician.

I assume these criteria are typical requirements for any health insurance that actually covers bariatric surgery.

The letter wasn't alarming in and of itself, but did include a passage that stated no services denied as medically necessary would be covered per their contract. I am hoping that doesn't mean all the preliminary appointments listed above that have already been completed, because I will fight tooth and nail if they try to deny those things--I only did them because insurance required them, after all. Since the providers call before every appointment to see if it is covered--and since they have said "yes" every time--I doubt the charges could be denied for any of this stuff. Given my past experiences with this insurance, however, I notice they have to be called and reminded someone is reading their policies, statements, and correspondence in order for them to actually fork over the dough.


It's been a weird few days--this is the first time in about ten years (save a day or two here and there) that I haven't taken any kind of sleeping pill. I am glad to be getting this stuff out of my system, because if the way withdrawal feels is any indication, I doubt it was doing anything good in there. I couldn't sleep at all for the first three days, then I crashed for about 12 hours. The past couple of days I have been sleeping in long blocks of time--today I could barely rouse myself at all. I've had cottonmouth and tingling hands, and the dreams I've had have been really vivid and intense, like being in the middle of 2 or 3 movies mashed together.

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This blog focuses largely on a personal journey to and through weight-loss surgery. It's also about reading, writing, animals, photography, love, humor, music, thinking out loud, and memes. In other
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