Appealing insurance - HELP?

[Thinkin about it 0]

After researching and deciding to face a Dr. to see if was a candidate for Lap Band I have visited withthe Dr. had the required Dietition and Phycologist meeting and after spending money and being told that I was covered 8020 by BCBS insirence the Dr office informed me today that I needed to have 2 other conditions since my BMI was under 40. I has asked about this previous and was told the only requirement I had was the 2 Dr. appointments I metntioned above, required by insurence but not covered financially. I was totally bummed out when todayafter talking with the surgen and getting excited about moving forward, this was the first day I let myself get excited - to be deflated by the insurence requirments. I looked and saw there were others with lower thn 40 BMI's that appealed the insurence, how does that work and why do you do that, and how?

Any help out there? - I am also checking into self pay, but not sure if that is a financial option for me at this time. :biggrin:

[rockstar 0]

Well, do you have any co-morbidities? Have you gotten a physical from your regular doctor or had any blood work done lately?

[Alisomniac 0]

After researching and deciding to face a Dr. to see if was a candidate for LAP-BAND® I have visited withthe Dr. had the required Dietition and Phycologist meeting and after spending money and being told that I was covered 8020 by BCBS insirence the Dr office informed me today that I needed to have 2 other conditions since my BMI was under 40. I has asked about this previous and was told the only requirement I had was the 2 Dr. appointments I metntioned above, required by insurence but not covered financially. I was totally bummed out when todayafter talking with the surgen and getting excited about moving forward, this was the first day I let myself get excited - to be deflated by the insurence requirments. I looked and saw there were others with lower thn 40 BMI's that appealed the insurence, how does that work and why do you do that, and how?

Any help out there? - I am also checking into self pay, but not sure if that is a financial option for me at this time.

I appealed and won - but this was from my insurance company, and the appeal was for consultation with the surgeon... I was then approved for the surgery once the surgeon submitted. I had to appeal to my insurance group because they didn't have the complete history of my weight and loss attempts, and I had to prove I met the criterion.

Do you have HMO or PPO? Did you have to have a referral to see the surgeon? That could make a difference in your outcome. Or did you just submit through your Primary Care Doctor? I have BCBS too and my psychologist visit was a co-pay because I was referred to him.

As for the requirements, they are there for a reason - to make sure the surgery doesn't become a quick-fix for so many people - it's a major change. And a permanent one.

Best of Luck, if you have questions, just message me directly.

[Thinkin about it 0]

Thanks everyone first of all for your words of wisdom and compassion.

I do not have sleep apn., dont think I am diebetic but have a family history of it. I am going to my family dr for a check/physical for high blood pressure and high choloest.

I have a family history of obesity, my mom had LB 2 years ago and it has changed her life, and her marrage her total out look is differnent.

I know for sure its not a quick fix, I am looking for a life style change so I know the rerquirements are with warrant, for sure! I am scared that if I dont take control of my weight, and I have tried on my own, that I will be 300 lb before I know it and even more deepply depressed!

Thanks again and any other words of wisdom I am open for!

--- What is the option that you took from your employer and how was your only $7,000? if you dont mind me asking!

[losethemess 14]

Well it sounds like your doctors office has not submitted anything to your insurance company yet. That's good. If you are close the required 40 BMI, you can try to gain a little weight in order to meet the insurance requirements. I too have BCBS I think I paid like 10% out of pocket. I was required to have a 40 BMI. I didn't so I did what I had to do in order to meet the 40 BMI. Like I said you can gain weight or wear extra cloths, drink lots of Water and wear weights in your close during your weigh in. In box me and I'll tell you exactly what I did. Once I meet the BMI requirement, because I did not have the co-morbidities I did the 6th month medically supervised diet. I was banded on August 16th. Good luck.

[Alisomniac 0]

I agree in part with previous reply. Work with your doctor (but don't wear weights to hit the 40 mark... it's cheating and unnecessary, most likely).

My doctor was great (for the most part- forgot to fax in the paperwork once). He understood I needed this. I don't have co-morbidities but I am insulin resistant (basically pre-diabetic), and have some elevated liver enzymes and higher than normal, but not yet serious cholesterol... a routine blood test found this all out. I meet on the BMI-only criterion, so this helped.

Once you have your blood panels done, you will know if you are diabetic, high blood pressure etc... and these conditions will help your claim. Also, you said you are 'deeply depressed'... this may be an exaggeration, or not, but talk to your MD who is submitting the claims - depression may be considered a co-morbidity (not sure on this, but it will help if documented).

Don't see specialists until you are directed to do so by the process... I didn't see the nutritionist or psych until I was waiting for final approval which was submitted by the surgeon. The nutritionist was through his office and free, and only had a copay for the psych.

Like I said, i qualify on BMI alone so it was almost a guaranteed approval one my doctor recommended me (HMO- Med Group Approval)... the Med Group denied me for lack of history, and I appealed to BCBS (easily overcome in less than 4 weeks) and won the right for consultation with the surgeon. He submitted and 9 days later I had my final approval.

Best of luck! Try to work with the process, and not independently - it will make it more logical and probably cheaper.