Very Upset. I was Denied Today

[Mert 0]

wow what an ordeal. I got my letter today. I has a long disclaimer in it , but I called to clarify and I guess that is about as good as it gets for acceptance letters from BCBS. I know what you mean about it becoming an obsession. It seems I have been working on this day and night all summer!! I don't know how you waited a whole year. I was about to go stir-crazy before I got the call from BCBS and I still may before I get banded.

[em1125 0]

Hi all,

Thought I would give you an update. As of today, my appeal was denied again. I can't believe it. Anyway, I spoke with my surgeon and I am going to self pay. At the same time I am hiring Kelley from Obesity Law to try and get my money back. As of right now my surgery is scheduled for Sept. 5th. I'm trying to get it done sooner. We'll see.

hugs all

[Bettina 0]

I wish you all the best!! As someone who is going thru the process to get approved, I was wondering: Why specifically are they denying you? Are they saying you are too healthy?? Not heavy enough? I just called my insurance about a confirmation for the sleep apnea and the woman in the eligibility dept said she didn't know how i got approved!! (heart was stopping at that moment) it seems that they still had me listed as working for the electric company and having full benefits...funny cause I quit the elect co back in 2000 and got rid of my benefits with them in 1995!! So i was glad I called because that info may have stopped me from getting approved luckily i caught it before the doc has put in for the surgery!!

[em1125 0]

Thanks Bettina. Good catch! You're lucky.

Anyway, the insurance letter reads that I have a BMI of 39 with no co-morbitities such as sleep apnea, severe heart conditions, diabetes etc. So the answer basically is that I'm too healthy and not fat enough. I'm so upset. I am going to self pay and maybe pursue reimbursement later on with an attorney. The only thing that scares me is if I self pay $23,000 which covers the Hospital for overnight and Operating room costs, surgeon cost, general anesthesia costs and upper GI series. However, if complications arise, that would be an additional cost to me. If the lapband needs to be removed due to complications that's an additional cost of $20,000. That's very concerning to me. Hospital costs can run very high.

MY PCP does not want me going to Mexico to have it done. He wants me to have it done here.

So that's my story. I'll keep you informed. Please let me know your status as soon as you find out anything. Good luck. My prayers are with you.

[Mert 0]

I am so sorry that you have been denied again. Please keep us updated. I'm glad to hear that you are going ahead with the procedure, though. Don't give up. My prayers have gone up for you.

[wantlapband 0]

em1125

What information did the doctor submit for approval for the surgery?

I'm just wondering what type of information they send to them....

I know when I met with the surgeon, he just asked me questions, and that was it..like what I had...so what do they send??????

I'm soooo sorry!!!

[em1125 0]

Hi all,

Wantlapband, I am so sorry I'm responding a week later.

My surgeon's office sent all of my documentation, ie. 1 year of medical weight loss supervision, 5 years of progress notes from my PCP and notes on my back surgery as well. My PCP and surgeon sent a letter on my behalf stating that it was medically necessary. I was denied. We then appealed and sent another letter of dispute from my surgeon. I was denied again. The denial basically said that I have not had a high BMI for a long period of time and I don't have life-threatening co-morbitities.

I have scheduled my surgery for Sept. 5th. I am self-paying. However, I have hired Kelley Lindstrom (Obesity Law Advocacy) who is in the process of appealing to the external review process. (my last shot) In the meantime, I don't want to wait any longer. If it gets approved, GREAT. If not, I tried my best.

With all the stress that I have been under, I hit my BMI of 40. Kelley had me see my PCP so that we could include that progress note to the external review. The only problem is that the insurance company wants to see a BMI of 40+ for over one year. The denial letter had stated that my BMI has been between 28 and 39 for the last five years and for the most part my BMI has been 35. I have gained the majority of my weight in the last year and they don't see that as a long history of morbid obesity.

My insurance company states that surgery is covered if the patient has a:

BMI of 35-35.9 with 2 co-morbitities or 40 + BMI with no co-morbitities. Kelley feels that we have a good shot with the external reveiw board. We'll see what happens.

I would also like to say thanks to all of you. Everyone on LBT has been so supportive. If I just need to vent, someone has always been there. I have learned so much from all of you. At this point, I am so well informed that I have to say, the only thing I couldn't do is perform the surgery. LOL. I would never have known about appeals, obesity law, writing appeal letters, without the support and guidance from all of you. You all have helped me become stronger during this process. I am so thankful to have found such wonderful and caring individuals as I have on LBT.

My prayers and thoughts are always with all of you.

hugs,

em

[wantlapband 0]

hi,

I'm so sorry to hear that.

I'm afraid that my insurance won't cover me because of my low BMI, even though I have comobities. I hate this feeling. The surgeons office haven't sent in my paper work to my insurance company yet, they are waiting for my psych letter which I am picking up today and my nutrition visit which is this thursday along with another upper GI.

Did you finance to pay for yourself?

If I get denied that is what I would like to do, but I don't know if there are medical loans out there? Otherwise I wouldn't be able to get it.

[em1125 0]

Luckily, I don't need to finance. I know there are loans out there. Somewhere on LBT they spoke about financing the surgery and banks that offer this. Put it out there and see what type of responses you get. I know someone on LBT will give you banks that offer this loan.

Good luck.

[wantlapband 0]

I'll have to look just in case.

I wish I didn't have to go through the insurance company and have money on my own to pay for it up front, because that is what I would do, right from the start.

[em1125 0]

Hi all,

I feel like it's been forever waiting for insurance to approve. I'm

[em1125 0]

Sorry,

I got cut off. Anyway, the hospital called me today to pre-register. Reality is setting in. I am self pay as of today. I will know by Friday if insurance will paying. I'm set for September 5th and I am sooooo nervous, but at the same time really excited.

hugs,

[Mvpo8961 1]

Will keep my fingers and toes crossed for you Emily that you get approved.

wantlapband look at Capital One Healthcare financing.

http://www.capitalonehealthcarefinance.com/

They are really good about financing.< /p>

Myra

[em1125 0]

I got the best news today. I WAS APPROVED!! :clap2: Thanks to Kelly and Walter Lindstrom my denial was overturned. I can't believe I'm finally going to be banded.

When Kelley and Walter took my case, I had a feeling that I would eventually get approved. I just didn't think it would be within 3 weeks of hiring their services. I am so thrilled yet soooo nervous.

Thanks to all of you who helped me get to this point. This would have never happened if I didn't have the support from my friends at LBT.

I am so grateful to all. Thank you very much.

hugs,

[Mvpo8961 1]

Yah Yippy Yahoo won't be long till your on the losing side.

Congrats.

Myra