Insurance - DENIED!!!

[wishes 125]

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! :-)

That is a great idea! Wow, you have given me something to focus my energies on just incase. When are you submitting to your insurance?

[GA Girl Best in the World 4]

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.

Is there anyway to forward me a copy to shermichael@yahoo.com trying to get approval from BCBSAL... Thanks so much!!!

[rsr53 1]

Diabetes in your family history is reason enough to appeal, Friend. Ask BCBS of CA whether they want to forever pay for your insulin in later years, or even support major heart attacks, strokes, hypertension and weak bones!!! Also, your doctor should go before their board of doctors in your behalf as mine did. I got approved the week of Apr 27th--surgery is May 31st. Appeal to them again and with fervor--you mean business!! I am rooting for you!

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.

[rsr53 1]

Don't give up! The Peer-to-Peer call is probably a blessing in disguise because your surgeon can discuss the reasons needed for your surgery to the med director at Aetna. My surgery did this with my Medicaid insurance carrier here in Phoenix. I needed the VSG revision surgery to get my health back on track. Your GYN probs, and the family history matters do play into the consideration. If your doctor is competent enough in facing the ins co, your surgery will happen. Mine did, and I go to the hosp on May 31st for surgery.

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!

[detchie 1]

I have BCBS Fed. They didn't cover sleeve last year when my husband had a band. They now cover the sleeve so its possible that they are in the process of adding to the plan. You may have to wait a few months. I would do the apeal and maybe by the time it lands on someone's desk they will cover. You should ask if they think it will be covered soon. Would be too bad if you got a loan and they added it to your plan in a month or two.

[xercisegirl 1]

Same happened to me today. Got a call from the hospital to confirm my info and when i called my surgeons office, they told me insurance denied. Waiting to hear about the peer to peer. So dissappointed as well. Bmi is38 and they are saying that PCOS, thyroid disease and all my other things like back pain, high cholesterol etc. are not comorbidities. Hoping this all works out for me and everyone else in the situation. Good Luck all!!!

[MaddMama 0]

Same happened to me today. Got a call from the hospital to confirm my info and when i called my surgeons office, they told me insurance denied. Waiting to hear about the peer to peer. So dissappointed as well. Bmi is38 and they are saying that PCOS, thyroid disease and all my other things like back pain, high cholesterol etc. are not comorbidities. Hoping this all works out for me and everyone else in the situation. Good Luck all!!!

Did you ever hear back from the "peer to peer?" I gave the exact same med. issues, but we haven't submitted for approval yet. I have Blue Shield Ca. and I don't want to start the sleep study and GI process if I know I will just be denied.

[former_vbg 198]

My suggestion to you is to move forward with your sleep study and the GI process, those things if found to be abnormal can only help your approval process. In fact, I wouldn't have your request sent to your ins. company until after those things are done. You want AS MUCH documentation as possible to support your request.

Did you ever hear back from the "peer to peer?" I gave the exact same med. issues, but we haven't submitted for approval yet. I have Blue Shield Ca. and I don't want to start the sleep study and GI process if I know I will just be denied.

[Eureka-C 20]

Wow, that was almost a year ago. I won my appeal, and had the vsg Nov 22nd. I have lost 83 pounds since I first started the process last July. I am very happy with my weight loss so far. I went from a size 26/28 to an 18/20 now. I want to lose 67 more pounds, but would be happy with 25.

[former_vbg 198]

Congratulations!!!

Wow, that was almost a year ago. I won my appeal, and had the vsg Nov 22nd. I have lost 83 pounds since I first started the process last July. I am very happy with my weight loss so far. I went from a size 26/28 to an 18/20 now. I want to lose 67 more pounds, but would be happy with 25.

[SmokyMtnGal2011 10]

As the other posts stated, don't give up. Dig in and be determined. The sleeve is the first part of the gastic bypass so technically, you can have this done, then wait on the rest of the procedure and not get the second part, the switch, done. I have heard of this happening. don't know if it will work for you, I would definitely APPEAL, APPEAL, APPEAL till they said yes. Good Luck

[SmokyMtnGal2011 10]

Great Job!

[xercisegirl 1]

I got approved a couple of days later with the peer to peer. I just called and called both my doc. office and insurance until I got the answer I wanted. Good Luck, hope it all works out quickly for you.

Did you ever hear back from the "peer to peer?" I gave the exact same med. issues, but we haven't submitted for approval yet. I have Blue Shield Ca. and I don't want to start the sleep study and GI process if I know I will just be denied.

[Guest Rosalind]

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.

When is your insurance year up? Policies change. Also, you can fight! It is ashame we pay insurance and they decide when to pay!

[Guest Rosalind]

Same happened to me today. Got a call from the hospital to confirm my info and when i called my surgeons office, they told me insurance denied. Waiting to hear about the peer to peer. So dissappointed as well. Bmi is38 and they are saying that PCOS, thyroid disease and all my other things like back pain, high cholesterol etc. are not comorbidities. Hoping this all works out for me and everyone else in the situation. Good Luck all!!!

Impact on joints is a comorbity for my insurance.