BCBS National Acct...denied, AGAIN!!!! HELP, what NOW!

[healthyliving 0]

Ok, so I am totally upset, disappointed, confused...etc? I was denied by my insurance (bcbs-national acct) after an appeal because apparently I have to have a BMI of 50+ for the sleeve. I understand they are considering that the sleeve is usually done as a firt step for patients who will later receive a bypass, but obviously that's not me. I am approved for the bypass or the band but NOT the sleeve. I refuse to settle when I have been a faithful customer for YEARS with my insurance company. I have been diagnosed with pre-diabetes, asthma, joint problems; amongst other issues. I just don't know how to get past this stage. I was scheduled for surgery tomorrow and I had to get it moved to another month because of my denial. My BMI is currently 40.9. Does anyone know how I can get past this stage? I am thinking I need to write my own personal appeal letter explaining in detail my story. Do you think this may help!!?!!

Any ideas, suggestions would be greatly appreciated!!!! Thanks

Peace & blessings...

[KinkySlinky 3]

What I would do is write a letter with statistics that you can find to help your argument (and make sure they are peer-reviewed articles and not from like wikipedia, also provide resources so they are able to verify the information.) But explain why the sleeve is better for you (lower BMI, you need a RESTRICTIVE procedure, not a restrictive AND a malabsorptive procedure, which might make you lose TOO much) versus the bypass, what steps you plan on taking post op to maintain the weight loss: gym, support groups, nutritionist, etc, how you have struggled for so long, all the steps you have taken to help you lose weight, etc.

Just make a veryyyyyyyy compelling argument... The people who review your cases are nurses and physicians... Make a good enough argument as to why the bypass is a bad idea (failure rate, lose too much, more complications), they just might let you do it...

Oh, and be SURE to mention that the sleeve procedure is cheaper than the bypass. That'll get 'em!

Good luck!

[NJMOMof2 17]

Get a letter from your doctor too. I had one even from my therapist!! My friend was denied twice then approved the third time around. Be persistent and keep trying. Good Luck. Sending good thoughts your way.

[KinkySlinky 3]

Oops

[bloomin_vjf 1]

I have Federal BCBS and was denied on the initial submission and then again on peer-to-peer review. I appealed and received approval at the National level because I had previous abdominal surgery (C-Section) and I already had a documented Vitamin D deficiency. Based on these two things plus a BMI of 43, Diabetes, Hypertension, and High Cholesterol, I was approved.

It may be the way your Blue Cross policy is written. Maybe there are other conditions that allow you to have the sleeve. Good luck - don't become discouraged. I hope to hear positive things from you very soon!

[StacyS 20]

I have BCBS-Fed too and was approved on the first try. I know you don't want to hear that but a personal appeal letter might be your best option. I have 42 BMI with no co-morbidities, so it is possible to get it approved!!! Do your research and even call your insurance company and see why they denied you

[kids05 4]

I was denied because my BMI was 'only' 40 and I had no major comorbidities. I was at high risk for Type II Diabetes, borderline HBP, borderline OSA, what nailed it for me is that due to back pain I take CELEBREX every day, sometimes motrin or aleve. You CANNOT take NSAIDS with other procedures...so the one thing I had precluded other weight loss surgeries! ou sai joint pain...do you take any anti inflammatories??? Maybe that will ramp up your next appeal??? Good Luck!

[kids05 4]

wow, wha happened to my letters, should be, **you said joint pain...do you take....