Insurance Denied !

[Cocoabean 430]

Dang, my computer is giving me fits. I was trying to add a response...it edited my previous...so please see my previous post for more information.

Include it in your next appeal. I quoted the 1991 consensus on my appeal letter when BCBS denied me due to the 6 month requirement. I won my appeal, but it was a few years ago. Almost 4 now.

[dustbuster_00 0]

Dang, my computer is giving me fits. I was trying to add a response...it edited my previous...so please see my previous post for more information.

Include it in your next appeal. I quoted the 1991 consensus on my appeal letter when BCBS denied me due to the 6 month requirement. I won my appeal, but it was a few years ago. Almost 4 now.

Thank you sooo much for that information. I guess we are not quite at the appeal state yet. My surgeons office say that they can do a peer to peer. The Insurance company medical director has to contact my surgeon and speak with each other. The medical director can overturn their decision. My surgeons office says that they have never sent that much diet information for one patient. They cannot believe that they are still trying to say there is not enough documentation. The insurance company will not come straight out and tell me what it is that is missing. They tell me that there is not enough documentation of a COMPREHENSIVE 6 month medically supervised diet and increased exercise. Although they have a 6 month daily food journal that includes exercise. Attached is a letter from my primary Physician stating that he advised me to go on Weight Watchers and personally saw me exercising. I don't know how they can deny it. If they are looking for medical records from the doctor seeing him monthly while on Weight Watchers, I don't know of anyone that sees their doctor every month while on Weight Watchers, nor does Weight Watchers recommend seeing your doctor every month.

[Cocoabean 430]

Thank you sooo much for that information. I guess we are not quite at the appeal state yet. My surgeons office say that they can do a peer to peer. The Insurance company medical director has to contact my surgeon and speak with each other. The medical director can overturn their decision. My surgeons office says that they have never sent that much diet information for one patient. They cannot believe that they are still trying to say there is not enough documentation. The insurance company will not come straight out and tell me what it is that is missing. They tell me that there is not enough documentation of a COMPREHENSIVE 6 month medically supervised diet and increased exercise. Although they have a 6 month daily food journal that includes exercise. Attached is a letter from my primary Physician stating that he advised me to go on Weight Watchers and personally saw me exercising. I don't know how they can deny it. If they are looking for medical records from the doctor seeing him monthly while on Weight Watchers, I don't know of anyone that sees their doctor every month while on Weight Watchers, nor does Weight Watchers recommend seeing your doctor every month.

You are most welcome. Many insurance companies are saying that a person needs to see their doctor or nutritionist monthly during the 6 month program. It's crazy what they will do to get you to go away. I hope the peer-to-peer works out for you. Don't give up the fight. There are many on here who had to go to the second level review before getting the decision overturned.

My PCP told me that in the medical group he was in at the time, a referral is always denied (that is what happened to me), but if the patient appeals, it is almost always overturned. I hope after you win, you will stick around here and help others through the process. My PCP was very impressed with my appeal letter. He asked if he could put it in his personal file for future reference! He had gastric bypass about a year after I got my band (by my surgeon, too!).

In today's world, we have to be our own strongest advocates! Keep up the good work, you deserve it.

[dustbuster_00 0]

Found out today that my insurance finally approved my Lap Band!

It was a fight to get them to approve it. We had to send a letter back to them the third time with directions on where they can locate what they wanted in my documentation. It was crazy like no one even looked at it in the first place at the insurance company.

I will be banded June 24th 2011. I am really excited.

[Asherscrashers 43]

Yay congrats! All that work will be so worth it

[brookster 0]

Oh! do I sympathize! We also have BCBS. Sent in all documentation months ago - was denied 2x for same reason - not documented 6 month weight loss program - had been seeing endocrinologist for last 3 years; every month for past 6 months - they weighed/advised on diet/documented monlty discussions, etc. and also periodically met with their dietitian - denied because "wasn't medically supervised,e tc. "- I argued that Weight Watchers isn't really "medically supervised" nearly to the extent that a personal physician who is part of a Weight Management Group - also includedd 1 year of Weight Watcher records but from 18 months ago.

Finally, got approval yesterday - surgeon did a Peer to Peer that was also denied. The Appeal by us however finally got original decision overturned. It turned out that my former employer required participant in a specific program "" Better Health" but that was not available to us. I also but BCBS directly in touch with endocrinologist so they could tell her EXACTly what they needed in writing. While the denials took 48 hours or so each time, approval took almost 3 weeks!!! But it is done and surgery scheduled for 2 weeks.

Don't give up; be a squeeky wheel.

[dustbuster_00 0]

Oh! do I sympathize! We also have BCBS. Sent in all documentation months ago - was denied 2x for same reason - not documented 6 month weight loss program - had been seeing endocrinologist for last 3 years; every month for past 6 months - they weighed/advised on diet/documented monlty discussions, etc. and also periodically met with their dietitian - denied because "wasn't medically supervised,e tc. "- I argued that Weight Watchers isn't really "medically supervised" nearly to the extent that a personal physician who is part of a Weight Management Group - also includedd 1 year of Weight Watcher records but from 18 months ago.

Finally, got approval yesterday - surgeon did a Peer to Peer that was also denied. The Appeal by us however finally got original decision overturned. It turned out that my former employer required participant in a specific program "" Better Health" but that was not available to us. I also but BCBS directly in touch with endocrinologist so they could tell her EXACTly what they needed in writing. While the denials took 48 hours or so each time, approval took almost 3 weeks!!! But it is done and surgery scheduled for 2 weeks.

Don't give up; be a squeeky wheel.

Congrats to you as well. BCBS can be a pain in the rear. Good luck to you after surgery.

[Cocoabean 430]

Awesome!!! Way to not let them get away with it!!

[Grider 92]

I contacted Blue Cross Blue Shield of Illinois today to check the status of my request for coverage. I was told that I was denied due to a lack of documentation of the 6 month required diet. The only thing that the insurance company requires is Documentation of active participation in a comprehensive, non-surgical program of weight reduction for at least six (6) months, occurring within the twenty-four (24) months prior to the proposed surgery.

They say they accept a recognized commercial diet-based weight loss program. I gave them copies of invoices from two months of Nutrisystem and 6 months of invoices from Weight Watchers. Now I am pretty sure both of those are recognized commercial weight loss programs. So why am I being denied? It just does not make sense.

They have medical records from a Physician who was treating me with weight loss medication for three months.

I have seen a nutritionist.

I have seen the psychologist.

Anyone have any suggestions for me? PLEASE HELP

[Corize 2]

I pursued lap band surgery almost 2 years ago. Jumped through all the hoops, and all my surgeon & I were waiting on was the final okay from the insurance company. Two weeks before I thought I would be having surgery, they sent a letter denying me because they felt my health issues (related to obesity) could be treated without surgery. By then I was eating better & exercising, and had lost 30 lbs, (as recommended by my surgeon to make it easier to get by the liver) and was feeling better psychologically. Instead of appealing the decision, I let it drop, thinking I could do the weight loss on my own. I have regretted it ever since. I wish I would have appealed it and argued with them til the end. I have maintained my 30 lb weight loss but in the last 1 1/2 years, haven't lost any more. My insurance company stopped covering weight loss surgery as of April 1st, so there is no hope for me to have financial assistance from them now. My only option is to pay out of pocket. Not a cheap venture but something I am seriously considering because I don't want to waste the rest of my life regretting that I didn't do something about my weight. Good luck.

[SkinnyInside=) 5]

Congrats !!!!

[xavier 153]

Yay for your approval...you worked hard to get it and you deserve it! I have lousy insurance but I guess I am lucky I could scrape up the pennies to self pay...it was two years ago and my weight loss has been slow but I feel it was so worth it! I am a happy girl these days and since I never dieted or exercised with this band(but did plenty of it in the past) I am thrilled with my results.Keep in touch you will get lots of support and honesty here...this site has a ton of tech issues but is packed with wonderful peeps!

Found out today that my insurance finally approved my Lap Band!

It was a fight to get them to approve it. We had to send a letter back to them the third time with directions on where they can locate what they wanted in my documentation. It was crazy like no one even looked at it in the first place at the insurance company.

I will be banded June 24th 2011. I am really excited.