Insurance - DENIED!!!

[Eureka-C 20]

So, here I was waiting for the call. The one from Dr. Davidson's office (Bariatric Surgery Center of Dallas)to let me know that I was officially approved. When I answered the phone on Monday, I was soooooo happy to hear her say, "This is Dr. Davidson's office" and then WHAM! She told me that although I met the qualifications for both gastric bypass and lap-band surgery, my insurance (Blue Cross Blue Shield of California) does not cover the sleeve. I was overwhelmed by an intense disappointment. I don't want the other two surgeries, and this (the gastric sleeve) is the best one for me. I told my hubbie that I would just go without, but he knows me and said to find out how much self pay is and we will just find a way. So I did, and here we are. I think we are going to get a loan and pay it off.

[YOLANDA240 13]

So, here I was waiting for the call. The one from Dr. Davidson's office (Bariatric Surgery Center of Dallas)to let me know that I was officially approved. When I answered the phone on Monday, I was soooooo happy to hear her say, "This is Dr. Davidson's office" and then WHAM! She told me that although I met the qualifications for both gastric bypass and lap-band surgery, my insurance (Blue Cross Blue Shield of California) does not cover the sleeve. I was overwhelmed by an intense disappointment. I don't want the other two surgeries, and this (the gastric sleeve) is the best one for me. I told my hubbie that I would just go without, but he knows me and said to find out how much self pay is and we will just find a way. So I did, and here we are. I think we are going to get a loan and pay it off.

Good Luck with your loan, what a emotional roller coaster....Keep your head up. I'm still waiting to hear from my insurance company and I fear they will say the same thing.:001_tongue:

[SarahD. 0]

Hang in there and don't give up yet. I think there is a way to appeal the decision. If you can show how it will benefit THEM if you have the surgery it might make a difference. Also, checking out the self pay route is a good idea. I was self pay and I am so surprised that we (my family) were able to pull it off. To me that is a miracle just by itself! Great things happen, just hang in there!

[Eureka-C 20]

I looked into appealing, but as the reason for the denial was "experimental procedure" and I don't have any other health concerns (other than mild edema) at this time. I don't really have a leg to stand on for appealing. I am doing this because everyone in my family has diabetes for 3 generations back. All due to being overweight. Most don't live over 65. I don't want this to be me.

[Kelkie 0]

You could at least try to appeal. Many of the insurance companies (especially BCBS) are saying no just because they know that people won't appeal.

I had BCBS North Dakota. I submitted and was denied. Then my surgeon's office wrote a letter of appeal, and I wrote my own letter to go with it, outlining that this surgery has been performed safely for decades, and that it is a viable option for weight loss. I also told them in the letter why I felt it was medically necessary for me (you could list your families health history as reasons). I got approved. The insurance companies want us to just take no for an answer. Good luck in whatever you decide to do.

[Eureka-C 20]

How long did it take them to process the appeal? Would you be willing to share your letter with me. I won't copy it, just to get an idea of what works, and make it my own. That is hopeful news, thank you.

[thisislou 13]

I have BCBSIL and was denied - appealed and was accepted. Come to find out 2 weeks later on July 1 - they changed their policy and now accept VSG - it's not "investigational" anymore. I read on this board someone else that was denied by BCBS - called them up and read their policy to them and was accepted. I had my doctor submit my paperwork but did all the calling myself. A few times they were waiting for something I was able to supply on the phone. Remember - they are approving you and the procedure - not your doctor. My suggestion is to find their policy on line and read it.

Lou

[Kelkie 0]

How long did it take them to process the appeal? Would you be willing to share your letter with me. I won't copy it, just to get an idea of what works, and make it my own. That is hopeful news, thank you.

It took about 3 weeks. PM me your email, and I would be happy to share my letter with you. Attached to it are a lot of references that you can check out, and may be able to tailor them to your needs.

[jamey 1]

I was denied by my insurance as well. I did not appeal because I had a friend who actually had more criteria met than I did and was denied on her appeal (Kaiser So Cal). I chose to self pay and let me tell you, it was the greatest thing I have ever done for myself. Don't get me wrong, in the first few weeks I wondered aloud several times if I had done the right thing. But I am now three months out and 63 pounds down.. I have moved out of the obesity category and into the overweight category. I feel great and can eat most anything I want (and yes, I am finding it easy to make good choices). Once you start losing the weight and see the health benefits it is easy to choose the good stuff. I hope you get approval on your insurance, but if you don't please don't give up. I looked at it like a car loan, only this "vehicle" must last me a lifetime. It is scary, I know. But with a good doctor and staff and this support board you will find that it is easier than you think. Good luck to you!

[giftoflife 0]

I was exactly 1 week away from my gastric sleeve surgery date and the bariatric center called me and said my insurance (Aetna QPOS) denied me the procedure. They have a ton of requirements to qualify for surgery, 1 being 6 months of doctor visits, 2 years of weight loss history and what they told me was that because I was not over 40 bmi for the past 2 years that it wouldn't be approved. What a punch in the gut that was. Of course, my surgeon is out of the country on vacation so he can not call prior to next week - so surgery put on hold. I called the insurance company and they said the doctor had to do a "peer to peer" consultation, the surgeon and the medical director at Aetna. This is a phone call to explain why the surgeon thinks I should have the surgery. If all goes well (please cross your fingers for me) then they will be able to reschedule my surgery asap. If not - then the appeal process begins. I am hoping this is not the case, but I can only play this by ear for now.

I never knew that being a "healthy" obese person could work against you, but since I don't have any co-morbid problems like diabetes or high blood pressure - they have to hope that my history with PCOS (Polycyctic ovaries) or a family history of high blood pressure and diabetes will work to my advantage.

If you pray - could you send one up for me???

Thanks!

[Eureka-C 20]

That's basically what I put in my letter, the family history stuff, emphasizing I wanted to prevent my body from falling apart due to diabetes like the rest of my family. My prayers go out to you. I finally was sleeved in November and I have lost 75 pounds since this all started.

It is an awful feeling, that phone call. Just don't give up hope.

[prairiedawn 0]

I was exactly 1 week away from my gastric sleeve surgery date and the bariatric center called me and said my insurance (Aetna QPOS) denied me the procedure. They have a ton of requirements to qualify for surgery, 1 being 6 months of doctor visits, 2 years of weight loss history and what they told me was that because I was not over 40 bmi for the past 2 years that it wouldn't be approved. What a punch in the gut that was. Of course, my surgeon is out of the country on vacation so he can not call prior to next week - so surgery put on hold. I called the insurance company and they said the doctor had to do a "peer to peer" consultation, the surgeon and the medical director at Aetna. This is a phone call to explain why the surgeon thinks I should have the surgery. If all goes well (please cross your fingers for me) then they will be able to reschedule my surgery asap. If not - then the appeal process begins. I am hoping this is not the case, but I can only play this by ear for now.

I never knew that being a "healthy" obese person could work against you, but since I don't have any co-morbid problems like diabetes or high blood pressure - they have to hope that my history with PCOS (Polycyctic ovaries) or a family history of high blood pressure and diabetes will work to my advantage.

If you pray - could you send one up for me???

Thanks!

Sorry to read your post. The same thing happened to me yesterday. My surgery date is set for 6/1 and insurance denied me. Call with doc and medical board is scheduled for today and hoping they approve it. I have UHC and in Jan. I was told VSG was covered. Went through all the necessary tests and seminars and i was denied. So upset.

I am really hoping it gets approved. I will be thinking of you....Keep me posted!

PD

[prairiedawn 0]

I received a call from my surgeon's office ystrdy that the insurance may be overturning my appeal afterall. All I need to do is provide them with my psych eval which doesn't take place until next Tues and my surgery is set for June 1st....Hopefully that will still be the case.

I hope to see some changes on everyone's end as far as their appeals.

Good Luck and keep thinking postive!

PD

[wishes 125]

Don't give up hope, Eureka-C!

Oh wow, prairiedawn that is great! I am glad to hear good things are happening for you. I have UHC and I am terrified of getting through all the hoops they have and not getting approved. Your positive attitude is inspiring.

[losingitin2012 3]

I have UHC, too...and have gone through all of the hoops for 6 months. I hope to be approved the first time around, but if not, I already have an appeal letter written by myself and by my doctor! :-)

Don't give up hope, Eureka-C!

Oh wow, prairiedawn that is great! I am glad to hear good things are happening for you. I have UHC and I am terrified of getting through all the hoops they have and not getting approved. Your positive attitude is inspiring.