Ins Denial Reasons (Psych)

[poslisa 0]

I just received word last week that my ins (BC/BS Teamsters NY) denied my claim to have the lapband surgery. They state that they denied me because I did not lose 5% prior to submitting claim and also that my psychiatric evaluation deems me not a good candidate for procedure?? My question is, has anyone else been denied the procedure because of the psych eval? That was the last reason I thought that they would give. My starting BMI is 36.5 and my MD told me to be careful about losing too much weight prior because it would drop my BMI below the 35. I have multiple co-morbidities (sleep apnea, high cholesterol, back issues, etc.). I just can't figure out the psych eval part of it. Has anyone else had this happen and how hard/easy was it to appeal just that issue. Go figure, the one issue I wasn't worried about and they deny me because of it.

Thanks. Lisa

[spoiltmom 44]

Do you have a copy of the eval? If not I'd get one and see what it says.

As for the 5%, I'm not sure about that. You're doc is right though your BMI is borderline so I wouldn't lose too much if I were you.

[honk 780]

You need a copy of the eval which you have a right to. Get it and call the insurance company and ask for your case manager and find out what the problem was.

[Cleo's Mom 257]

Some insurance companies want to be shown that you can be committed to weight loss before the band so that you will be committed after it and require you lose a certain %. If yours says 5% then you should try to lose that. It's probably not a lot of weight if your BMI is 36.5.

As to the psych eval. - I agree with everyone else in that you need to get a copy and review it. Appeal their decision and keep after them. Don't give up. That's what they're counting on. Good luck.

[poslisa 0]

Thanks for your responses. I see the surgeon on Monday for another weigh in to see if I am down the extra 5 lbs that I needed. At that time, I will ask them for a copy of my eval and get on the phone immediately with insurance. Thanks for the input.

[GipsyGirl 6]

I was denied the first time because I did not have a note from my psychologist stating that I am controlled well on all my meds. Then I got the letter within a week and it took them another week to approve me.

[krasc001 0]

Some insurance companies want to be shown that you can be committed to weight loss before the band so that you will be committed after it and require you lose a certain %. If yours says 5% then you should try to lose that. It's probably not a lot of weight if your BMI is 36.5.

As to the psych eval. - I agree with everyone else in that you need to get a copy and review it. Appeal their decision and keep after them. Don't give up. That's what they're counting on. Good luck.

See that's where I start to see red and get confused because if I individuals be committed to weight loss, then they could lose the weight wouldn't think to seek out such measures. That pisses me off.

[honk 780]

FYI when you ask for copies of your medical files they may charge you for them. I was once chaged $15 for 3 photocopied pages:confused:. Just wanted to let you know so you don't feel blindsided.

[jenn90808 0]

I remember chatting with my consultant at the Dr.s office about the psych eval. She said that it was necessary to determine whether a patient's motivations and expectations were realistic and healthy. If a patient answered that the reason they wanted to lose weight was for someone else it was a red flag. Or if someone thought their lives would be perfect once they were skinny that was a red flag too. A history of substance or alchohol abuse also resulted in a denial.

[poslisa 0]

Well, went to see my surgeon yesterday and I have now lost the 5% that they insurance company wanted. I asked about my psych eval and asked if I could see what it said and why was I denied due to it. I was read the report and no where did the evaluation say that I was a poor candidate. Actually, it said that I was a good candidate that should have good results with the placement of a lapband. I explained to the surgeon about my denial letter and they looked at the one that they recieved and there was nothing about being denied because of psych eval only because the 5% weight loss was not achieved. So much for thinking I was crazy for the past two weeks Surgeon's office is resubmitting my paperwork as of yesterday and I should hear in the next day or right after the holidays! Thanks for your responses.

[ElfiePoo 109]

Sounds like all systems are go and they now have no reason to deny you. Good luck!

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