Very Upset. I was Denied Today

[em1125 0]

Hi all,

I am so upset. I just found out today that I was denied the surgery. They said it was not medically necessary. I have a BMI of 39. If I'm not fat enough, that is truly pathetic. My surgeon's office is appealing the denial. Is that usually the course of action. I was thinking about writing a letter in addition to the surgeon's appeal. What does the surgeon's office do as far as appeals go? I need help. Please let me know what you all think I should do. I was scheduled for July 11th and now who knows when I'll get it done.

Emily

[Scribby 0]

I was denied three times before I got approval. It took me a year to get throught the insurance bs. You should find out what they need to appeal it. I only had a certin number of appeals so find out all the info you can before actually doing it. Mine is scheduled for August 9th , but for real, I am still secretly scared that its not approved. I made then send me in writing that I am coverd but havent gotten it yet. I have been stalking the mailbox. Seriously, when you go to appeal, have your surgeon letter and like a reg doctor write one too..anything would help!

[Scribby 0]

oh and by the way, when i got the first denial, I sat out in my driveway bawling my eyes out..so if your doing that, I know exactly how that feels!!

[em1125 0]

Thanks for the support. I just went online to Obesity Law and got a lawyers name that deals with denials for this surgery. As a matter of fact, the lawyer is a bariatric patient himself. I'm so angry I will do whatever it takes.

Thanks so much.

emily

[Morsaille 4]

http://www.lapbandtalk.com/showthread.php?t=20086&highlight=fought

I think this is the thread that discusses the legal process with Obesity Law who you should contact especially if you can prove medical necessity.

[NancyRN 1]

Hi Emily,

That sucks! Here are some ideas for what to do now:

1. Find out exactly why you were rejected. For instance, if they decided it wasn't medically necessary, why not? You may be able to find this out from the insurance co. or maybe your doctor will need to.

2. Check out www.obesityhelp.com. Click on forums and scroll down until you see "types of surgery" and "lapband".Look on this forum until you find their "how to" guides: calling your health plan, choosing your strategy, etc. Find the section that contains a sample letter to send to your insurance company. It's excellent and perhaps you could enter an appeal following its format.

If you can't find it that way, go to http://obesityhelp.com/content/chooseyourstrategy.html. The letter I refer to should be somewhere in that vicinity, perhaps the topic after this one.

I'm sorry I can't give you better information right now on how to find this. My computer won't let me access the site for some weird reason. If you can't find it, let me know and I'll keep trying to get on the site and find it for you.

3. Ask your surgeon to reapply using the new CPT code for lapbands. For details, see the sticky at the top of this forum.

Keep us posted,

NancyRN

[CCBSTX 0]

So sorry about your denial! Do you have any comorbidities (sleep apnea, pain, diabetes, etc)? Sometimes, as "sick" as it is, that helps to get approval.

Shawn

[ericsmom 2]

I agree with Shawn - the more you have wrong with you, the better chance you're going to have getting approval. I have obstructive sleep apnea and bilateral degenerative osteoarthritis of the knees and a BMI of 57.8, so as soon as I had benefits that would cover it I was approved.

[em1125 0]

hi all,

Thanks for all of your responses.

NancyRN - Thanks. I went to the website and got a sample letter. I am waiting for my surgeon's office to call me. They said they put in the first appeal. I am also going to write a letter along with my PCP. We'll see what happens.

shawn and Stephanie- Thanks for the support. My BMI is 39 with Co-morbitities of high cholesterol, chronic hip bursitis, chronic neck and back pain for years in addition to having cervical spine surgery in 2002. I am also receiving cortizone therapy in my hip to relieve the pain. I had even wrote an excellent letter to my insurance company along with progress notes of one year supervised monthly visits from my weight doctor. (medifast) I also had my PCP progress notes for several years showing weight issues as well.

My surgeon's office told me that I should never have had any problem getting approval. I had more than the insurance company requested for pre-approval.

I will do whatever I need to do. I want to fight with them first and if worse comes to worse, I may have to pay out of pocket. That truly gets me very angry. I want this surgery before I start having major health problems. Diabetes and heart disease run in my family. That's all I need.

I'm hoping that this is common for my insurance company and after the appeal they may approve. I called an attorney, but he hasn't called me back yet. Wish me luck. If you have any other input, please feel free.

Thanks.

Emily

[Elisabethsew 50]

Call your insurance company and ask for your case manager. This is the person who has your file and can read to you what the reason for the denial was. Once you have this information, you'll know how to proceed. I did not find the surgeon's office helpful in the appeal process. You have to take the bull by the horns and FIGHT.

[em1125 0]

Thanks Elizabeth. I am going to call tomorrow morning.

Emily

[melmcc99 0]

Hugs to you. I know exactly how you feel. I was denied two weeks ago and spent 2 days crying. My husband felt so bad for me he went to the surgeons office and asked for help. They told him about the appeal process and all about self pay. Also, I am a 38 bmi, with High blood pressure and kidney disease and their reason was the same as yours..."not medically necessary" My goodness, how sick do ya have to be. Or maybe they just don't read things through the first time, they see under 40 and say NO!

Hang in there, I know how you feel. We will both get through this.

[em1125 0]

Thanks so much for your support. I hope you get approved as well. I'm already at Stage 1 Appeal. My surgeon and I have appealed and I'm waiting to hear. If Stage 1 Appeal doesn't go through, I will hire an attorney. Keep me posted on your appeal process.

Good luck and thanks again.

Emily

[pplqueen 0]

Make friends with the case manager. I did and was approved in a day. Make them your friend and then ask exactly what you have to do to appel and get approved. Sounds like you just need a few sickensses, I am sure that you have them .Co-mobidities do help..... pain, high blood pressure, snoring, sleep apnea, ect..... Good luck girl. I was scared t odeath but got approved very easily. I thank God for it everyday............

[melmcc99 0]

EMily, Did you get a letter from your primary physician saying it was medically necessary? Mine was very helpful with that since he does feel it is necessary to prevent further complications from the weight. I'll keep you posted. You keep me posted too.

Melissa