Question on insurance denial

[mama angela 22]

Hi...last wednesday my nurse coordinator emailed me to say insurance was denying my request! I couldn't believe it...I've done the 6 months meeting with a nurse, nutritionist and physical therapist, had my pschy eval, have sleep apnea, type II diabetis, high blood pressure and high cholesterol! The nurse said they are denying because I didn't meet with a doc for those appointments. I met with my doc prior and she okayed the program. Now, supposedly she is going to call them - but is out for a couple of weeks.

Should I contact insurance? Or would it be best to wait until after my doc does?

thanks,

[KAATNS 1,473]

I would probably appeal their decision, which will force them to take a closer look at it. Did a doctor sign off on the nurse visits? Maybe submit the doctor's letter with your appeal letter. Good luck!!

[mama angela 22]

Thanks Steph04. I didn't go back into my doc every month after my meetings with the others. I asked if I should and they reassured me that I didn't need to that they were filling in the doc on appointments.

My doctor has said she will appeal it - the insurance agreed to do a peer to peer review with her. I'm not sure what that means...but it sounds like that will be another 2 weeks out.

I've debated on calling the insurance company and asking them...but I don't want to mess up my doctors chances. ughhhh....and I'm so NOT a patient person.

[KAATNS 1,473]

I would wait on the peer to peer review then. If denied after that, I would appeal for sure. Good luck!

[JACKIEO85 308]

I'd wait for the peer to peer and if that is denied then appeal, then a doctor to doctor review can be done, then if that fails do an appeal to the insurance commission in your state.

hope this helps

[Jim1967 3,569]

I agree with others about the Peer review. That being said, all the people you did see are part of the same practice as your surgeon correct? I went to a center of excellence where all the resources are under one roof. I met my Doctor once during the 6 month monitored diet. Like you I saw the Nurse, mental health counselor, and Nut. for most of that time.

This definitely sounds like a proper documentation issue that your Center needs to straighten out for you. I was denied on day 2 of submitting because they did not get all the desired docs and they had my DOB wrong. Paperwork showed I was 17. LOL Once they straightened out those details I was approved two days later.

Stick with it and don't give up and talk to your doctors and ask them to advocate on your behalf.

[labwalker 1,177]

It may not hurt to talk to a claim resolution specialist at your insurance as well.

[kristinc1985 111]

Agreeing with everyone else. Don't get involved... Yet. Let them try to hash it out. If they make no leeway, FIGHT THAT NONSENSE!

[mama angela 22]

Okay...so an update. My doc had to go out of town for 2 weeks for an emergency...but she called the insurance yesterday...and they are still denying!

The nurse (I am in a program - the surgeon, nurse, nutritionist, physical therapist and my doc)...anyways, the nurse just emailed me this morning saying the insurance will not budge. They are saying I can start over and meet iwth my doc once a month and the nutrionist and physical therapist!!!!! I already did that - except meeting with my doc because the nurse was giving her the notes from my meetings. UGGHHHH... i feel sick to my stomach.

The nurse here at work wants me to get the denial letter and she wants to send it to our insurance liasion...so I will try that...but I'm so discouraged. I had wanted to have this done by mid May.

[AZ Gary 149]

Not sure if any of the local media outlets there has a consumer advocate, but that might be a good angle. I have seen a couple of stories on the local TV about insurance companies having a change of heart when faced with potential negative media coverage.

[mama angela 22]

Well...I am filing an expedited appeal. The initial guidelines do not state that I have to meet with a doc. So..I have a letter to insurance..the initial guidelines ....the referral from my doc to the medically supervised wls program....a letter from my doc mid way staring that she was informed of my progress...the notes from 6 month program....a copy of my sleep apnea report and the severness of lit with notes that I am obese and need to lose weight and that it would be helpful....a file notes from my orthopedic surgeon..last Oct when he specifically recommended that I get also.

Hopefully that will all help

[Cazzy 725]

Sounds like a nightmare for you but u need to start the meetings with your doctor now, don't wait around for the outcomes of appeals etc otherwise u have wasted a month of the 6 months they are asking for. Worst case scenario is that u have to wait another 6 months, its not ideal but waiting around is much better than a total denial. Is there a way your doctor could sign off on the visits with the nurse retrospectively ? I wish you good luck !

[mama angela 22]

The company I work for just got bought and they are looking at layoffs .. so right now they are saying I should not take the time off work..especially. since I just did that for the last 6 months....