Denied then straight to Peer-to-Peer

Lauran · October 14, 2010

Soooo...as some of you may know, my papework was submitted last week for VSG. The insurance coordinator at my WLS practice told me that it would be about a week before I heard anything back.

Well i called today and was told that I had been denied based on the surgery still being considered investigational (big surprise). Then I was told that my surgeon had already scheduled a peer-to-peer for Friday (tomorrow).

Is this a good thing, or a bad thing? Is this usually how it goes? Somebody help me out here...I'm confused...

6kiddos · October 15, 2010

I am not sure about the VSG, but when my cardiologist wanted to do a Nuclear Stress Test (based on TERRIBLE family history with my brother having a MAJOR heart attack at 40) she did a peer to peer review also. It was approved within the day. I would think on the VSG this would be a good thing. =)

What is your ins? I am waiting on Aetna. waiting...waiting...ugh.

peatie · October 15, 2010

I don't have experience, but i hear peer-to-peer is a good thing b/c the Dr can specifically talk up your case. Good luck!!

Lauran · October 18, 2010

Thanks y'all I'm trying to stay optimistic. I have BCBSNC. I will keep y'all posted...

NikiS · October 18, 2010

Hi Lauran. I have BCBS too and was told when I met with the surgeon that BCBS tends to deny sleeve requests because it hasn't been around that long. He also said that if that were to happen, he would have a peer-to-peer and would be able to speak with a rep from BCBS, talk about my case and my specific medical history. He said in instances like this, about 85% of the time it is approved but BCBS will requests that in a year or so, the patient has Part II of the process which will be gastric bypass. I was all ready to give the surgeon my rebuttal but he answered my questions before I asked...no, not all patients opt to have the bypass after having the sleeve. Whew...

Anyway, I hope this helps. Please keep us posted. At the end of this month I have my psych eval and meet with the nutritionist. On Nov. 9th I take my class and my info will be submitted to BCBS so it's quite possible I'll soon be faced with this very thing. No worries...we're winners so stay positive and be encouraged!!

Have a great day,

Niki