Denied Two Days Before Surgery

[audreycat123 59]

Well this will scare everyone waiting on approval, but I am being told it hardley ever happens....so lucky me I guess. I was scheduled for surgery this Friday and found out today that I have been denied due to an exclusion on my anthem policy. Wow. Psych eval, three nutrition classes, surgeon consult, and 2 meetings with nutritionist .... All an hour away from where I live......for nothing.

My gut reaction was to try to scrape together the 7500 down (1/2 of total) to go ahead with it, but after settling down I realize that is impossible. Has anyone had any luck getting around these exclusions? I have no comorbidities, bmi of 41. I will however need knee surgery if I don't lose weight- which I am sure anthem will pay for. I would rather have lap band surgery than have my knee tendons cut. I already did my left leg and the results sucked.

I was sooo excited this morning. Now I just want to go to bed for a month.

[angelize 50]

omg i'm sorry! thats horrible! i was worried about this also,i have ghi,and i never recieved an approval letter or phone call...my surgery was at nyu and throughout the whole process,everyone kept saying dont worry you will be approved.i had my surgery on oct5,got a letter from ghi the week before saying that the hospital stay wasnt approved,but not once did they mention the surgery! then nyu said dont worry about that letter,we will appeal it.

i am now 20 days post op,and im waiting for the letter to come saying that i owe $20,000!!

its funny how specific the insurance companies are on what their requirements are,but then when it comes time for them to pay,everythings cloudy!!!

[jen_1381 446]

I am so sorry. The same thing happened to me, two days before my surgery United Healhcare came through with a denial. My surgeon called and talked with their Medical Necessity board and was able to get them to reverse the decision. Can your surgeons office go to bat for you? Or, you can file an appeal. It takes time but most people have better luck the second time around.

I know how gut-wrenching this is, I was there...on pins and needles until they over-turned their decision. Good luck to you.

[Mommy1558 2]

Bless you! That is terrible. I have a clause in my medical insurance NO Weight Loss Anything. So, I had to do the self pay option. I did an anlysis of my health concerns for my future and being around for my children as they grow up then I decided to go for self pay. I would not change a thing. I just wish the insurance companies would realize that long term it is a win win for them when people don't develop comorbidity issues or get off medications and require less usage of the insurance. That coupled with the fact that people who live longer pay the insurance company more in the long run for the insurance premiums than the ones who die young from the complications of being overweight.

I hope you can find a solution!

[Pebbagirl 131]

Oh, my heart sank for you when I read the title. I don't have any words of wisdom (I'm self pay), but I know how disappointing this must be. I'm so sorry.

[thinkt2013 74]

I am so sorry

[kyrasgrandma 228]

I am sorry too. I am self pay and didnt have to deal with the insurance. They wouldnt have covered it anyway.

[DELETE THIS ACCOUNT! 12,703]

Oh I am so sorry. My heart just broke a little for you when I read your post

I agree with the above poster, you should ask your surgeon to appeal it for you on the grounds of medical necessity. I know there's no guarantees it'll work, but it's definitely worth a shot.

Hang in there ((hugs))

[434teresa 20]

what was the exclusion? Is it something guildline you did not meet or something like that.. Or will they just out right now pay?

[MDP32 9]

I'm sorry to hear that! What your denial because of your bmi? Find out what was the couse for denial and see if it's someting that you can fix. Did you meet all requirements? Don't give up if you really want it keep fighting til you get it!

[thinkt2013 74]

I work in the medical field, and see this a lot with therapy and such, but unfortunately it sounds like it isn't an insurance issue. When exclusions are on plans, it comes from the employer, because it makes the policy cheaper.I advise patients to call their HR department, and ask them them to make an exception to cover this. It can happen.

[depressed_bandster 72]

I'm so sorry for you...that is just heartbreaking

Have your doctor's office appeal for you. I read on her about a lot of people who have had to submit, appeal, re-submit and finally get approved on the 2nd & 3rd try. I don't understand it, but apparently its more common to have to appeal before approval than approval the first time. Your doctor's office should be familiar with how to do this. Stay on top of your doctor's office AND your insurance. With a BMI of 41, you shouldn't have to have a co-morbidity and that in itself is a medical necessity. What state are you in? I have Anthem BC in CA.

[Blondie638 98]

I am so sorry this happened to you! Stay strong!!!! Everything always works out in the end!!! Keep fighting for what u want!

[Lisa38 0]

Oh no! Fight fight fight!!