Denied For The 2Nd Time

[sharonk 23]

Just called my insurance and found out they have denied me for the second time! :( i have a bmi of 39 and must have a comorbitity. Well the first time they said there wasnt enough paperwork submitted by my pcp. This time i have yet to find out why until they send the letter in the mail but my drs office believes its because they think I'm too skinny and I'm only borderline comorbitity! They are going to do the Dr on Dr call next but i have a feeling I'm going to be denied across the board! So dissapointed and totally don't think its fair that insurance makes you take all these steps only to find out your not going to be covered! Ive been on this journey since mar2011! Something is just plain wrong with this! I know everyone says keep at it but damn this is emotionally draining and unfair!!

[ELMO4635 1]

^{Keep after them!! Don't give up.... Start right now and work on your diet and portion control... it will help you in the long run!!}

[DELETE THIS ACCOUNT! 12,703]

I am so sorry. It's insane that they put you through so much crap and all you're trying to do is get healthier. I wonder if these companies denying a relatively minor surgery, costing maybe $10k-$20k, have bothered to considered it'll cost them TEN TIMES that amount to treat us for diabetes, high blood pressure, heart disease, etc.

Keep at it, don't give up and keep fighting them.

[Oscar w 0]

I work for a County which offers zero exclusions so I had to finance the Surgery myself,Best thing ive done for myself, started 320 now 244! Feel Great and lookin forward to the Future!

[sharonk 23]

Thanks guys...I'm going to give it one more shot! I just hate waiting!!! I don't want to do out of pocket because I'm too worried about having complications and such and then having to fork out even more money that what was expected. Plus the fact that i don't have that kind of money.

[NWgirl 574]

I would look over their policy to a T, and if you satisfy all requirements and your Dr has deemed it medically necessary, then do whatever you need to do. I saw a post yesterday about a person who went through http://www.obesitylaw.com/index.php after being denied and they were ultimately granted approval.

I know if I am denied in my state, I can go to the state insurance review board and file a report against the insurance company because in Oregon if you meet all standards set forth in the policy and you are denied, it will not be looked at lightly.

Good luck and keep moving forward.

[c945105 14]

Hi Sharonk,

I agree and am in similar boat with UHC being denied and then appealed twice. See my long post in the United Healthcare subject in this forum. I would put out the outlay but like you mostly concerned with after the fact complications/fills and not being covered.

Anyhow, in my situation I feel they didn't write their policy well and are trying to be so subjective in their response as I don't have "serious co-morbiditiies". I have co-morbidities but my policy doesn't even call out that they are needed. Just need to be a BMI of 40 which I am right now and morbidly obese for 5 years. I was within 10 pounds of my weight only only there due to constant dieting so without a definition of morbidly obese I certainly think I qualify. Anyhow I'm going to the next step of a third party reviewer and hope they agree with me that they are interpreting a policy stringently and not what is written in it. I called yesterday and said I would go self pay but after thinking out it I'm still so bothered so I am going to do this next filing. If they really weant strict co-morbidities if you are just under 40 BMI then I think the policy better clearly write them out what they are. I saw on one of these that bcbs did just that in their policy so at least you know what to expect in response.

Anyhow good luck and I feel your pain. I am ready to change my life and I would definitley get diabetes and more if I do nothing which will cost them so much more as someone pointed out.

[sharonk 23]

I just printed the medical policy for my insurance (bcbs) and i don't think any of it can ever be totally clear to the average person. I think they do that on purpose .

Sorry to hear about your struggles c. I hate to say it cuz i don't wish this on anyone bit i am glad I'm not alone when it comes to this annoying insurance crud! Good luck to you also!

[1shauna1 129]

I was self pay because the band isn't covered in Canada....but it wouldn't surprise me if they put you through all of this hoping you will give up! So, don't give up! if you meet the requirements then they should be covering you.

[GermaineF 25]

Hi SharonK..I too was denied twice i have BCBS Illinois and after researching on my own and constantly calling EVERYDAY to BCBS I was approved with a BMI of 35...they also told me that there wasn't enough paperwork submitted so i called my dr and told them to resubmitt. then they denied me for only having 1 comorbitity. Then i called my pcp to schedule me for a sleep study and found out that i had sleep apnea, so dr submitted that paperwork and i was approved. But i called BC every single day sometimes twice a day until they got tired of hearing from me and this nice lady named Amanda said "ma'am let me explain the process to you. First your paperwork is reviewed by our nurse and she either approves/denies it then it goes to medical review for the dr. The nurse already reviewed yours and she approved it and normally the dr goes along with what the nurse says." I then got really excited!!! She said but it can take 7 days for the dr to review it so i will put a note for them to call you once they reach a final decision." (In other words, don't call us anymore, we'll call you) lol..So i hung up and later that day i called to see if they reviewed it yet and nothing..But the very next day I got the call telling me i was APPROVED......moral to this story is.....don't give up the fight, and don't wait for dr's office,or anyone to help you..Take matters into your own hands and run with it...

You need not wait for the letter to find out why you were denied, you need to call them and ask them why so that you can start working on getting what they need. It took 2 weeks for me to receive my 1st denial letter and i had already submitted my other paperwork by then...Good luck and let me know if you need some assistance....

So sorry for this long post...

[sharonk 23]

Thanks for your input G!...i have tried asking my insurance to tell me why they denied it but they say they don't have that info available to them?! Something about their system wont allow the reps to see it. Not sure what else i can do to get the info i need?! I'm guessing they are going to say that my 6 months of Dr./ diet supervision wasnt substantial enough but i did what my band Dr recommended. I really don't know though, I'm sure they can deny it on the slightest things. Argh

[kr8160311 36]

My drs office told me once someone got denied because they did't send in a form the ins company wanted. It can be something so simple. She also told me that if this happens to me she won't appeal it becuase that takes up to 30 days she will just tell the ins company to cxl the claim and resumitt what was missing so you need to have your dr office find out and maybe it will move things along for you! Good luck. I just got approved today from BCBS over the phone within minutes with a bmi of 40 and no co/morbs . good luck!

[sharonk 23]

You are right KR..it took more than 30 days to appeal it so you are lucky your Dr.s office know how to work the system well! It only took 4 days on the first submittal! I'm now waiting to hear about a Dr on dr appeal. The office told me that they would call me when they find out something. So i asked them what was a reasonable time to wait and she said this Friday. Ugh

[kr8160311 36]

ugh, the waiting games stinks but Friday is only a few days not months or weeks so hang in there!! Good luck!!

[angbutler0712 30]

Have you heard why they denied you yet? I was also denied twice, for not being able to prove that I was over a 35 BMI for 2 years and not having co-morbids. I spoke to an insurance representative and wanted to appeal a third time to my employer, but they told me flat out that I will not win because I didn't meet the criteria. I started my journey in 2/2010. I had to wait after Jan 2011 and start the entire process all over again to show the 2 years of being a high BMI. All tests, all those doctors appts, nutrition appts had to be redone.. it was horrible. Within that year, I was diagnosed with borderline high blood pressure (not controlled with meds) and osteoarthritis in my back. I was a 38 BMI at the time.. After all my testing was completed, my doctor resubmitted to Aetna October 2011. Took 3 weeks for them to finally approve me. I called them every day after the first week asking for a status. I was over the moon excited that I had been approved!

SOOOO.. Don't give up! Unfortunately for some people its more difficult. Read your insurance policies and make sure your doctor tests you for everything that could be counted as a co-morbity. I didn't have any of the major co-morbitites so I thought for sure I'd be denied again..

Good Luck!!