Keep Your Fingers Crossed...Please!!! Appeal was DENIED, now what??

[healthyliving 0]

So, my insurance denied my appeal and I freaked out! Once I calmed down I contacted the attorney general's office in my area!! I can't tell you how calming and helpful they were. Apparently, my insurance company denied me TWICE because in their medical policy it states that VSG is reserved for those with a BMI of 50+ and because I fall below that it's NOT considered medically necessary. Does that sound CRAZY to you?? So I had to draft a letter telling why I think VSG is absolutely medically necessary and send it to the attorney general's office and my insurance company. Please feel free to send me any advice or words of comfort. Have any of you EVER had to deal with your insurance company on this level, and if so....HAS ANYONE EVER BEEN APPROVED?? I am so anxious I can hardly think straight....lol. UGH!!!:blink:

[fatBgone 6]

Yes I was denied for my original request of a lapband, had an atty and appealed, that went on for 11 mos, ultimately I was denied. I moved forwarded, learned about the sleeve and got the sleeve as a self pay.

[kellyw74 258]

I can not believe that it is 50 bmi. That is outrageous!!! I have Kaiser and they pay for the surgery if you have a BMI of 40 w/o comorbities. and 35 with. I can not believe that!!

Definatley fight them!!

Good luck and keep us posted!

Kelly

[fatBgone 6]

Unfortunately they can set that at what they want and typically it's your employer who sets those rules. The insurance company just administers what the employer chooses to cover and not cover.

[healthyliving 0]

Ugh, @FatBgone, that is my biggest fear. That it will go all this way and they will still deny, deny, deny! I have a PPO and apparently they can make their own rules. This is what I was told. Part of me wants to just get a loan and get it done, but another part of me thinks they SHOULD pay for it. I have paid enough money to them to pay for this surgery five times over. I am SO frustrated and I don't want to go into debt for the amount of the surgery. This is going to bug me for sure....I hate to allow others to have any type of power over my thoughts and I am very big in meditating and letting things go....but THIS is sticking....#so angry#

[mina 27]

I have BCBS ppo and i was denied the VSG because it was "experimental" . Like you said I felt like they should pay for it because i pay a lot of money toward insurance and i am in fairly good health so i don't use my insurance very much. I thought about it but didn't have the energy to go through appealing and i'm on a time constraint so I will be self pay (im going to mexico). it will cost me the same as with insurance (deductable plus 20% of the surgery cost). the downside is i won't have my surgeon near me if i have complications and insurance won't pay for complications. If you are up to it to fight you should do it. keep us posted

Ugh, @FatBgone, that is my biggest fear. That it will go all this way and they will still deny, deny, deny! I have a PPO and apparently they can make their own rules. This is what I was told. Part of me wants to just get a loan and get it done, but another part of me thinks they SHOULD pay for it. I have paid enough money to them to pay for this surgery five times over. I am SO frustrated and I don't want to go into debt for the amount of the surgery. This is going to bug me for sure....I hate to allow others to have any type of power over my thoughts and I am very big in meditating and letting things go....but THIS is sticking....#so angry#

[snowfie9 6]

It's amazing to me that bean-counters decide what is "medically necessary" and people don't riot in the streets over it.

I don't know what to tell you but good luck with whatever you decide.

[fatBgone 6]

@healthyliving, good luck to and I hope you get somewhere w the atty gen.

[healthyliving 0]

Thank-you so much for the words of comfort and encouragement. I hope it all works out for me. I love reading the stories from you all and all of your experiences!

[healthyliving 0]

Update: I appealed the decision through the Insurance Administration JUST to find out that MY insurance does not have to answer to them! I AM SO SAD! I don't know where or what to do and a lawyer is over a grand. Don't have that just sitting around for a MAYBE....lol. UGHHHHH!!!!!

[Cinderella 2]

@healthyliving, if your insurance policy does not specifically exclude bariatric surgery, then you have a chance to be approved. You need to do the following:

1- carefully read your policy.. read the whole dang thing... front pages and the sections on bariatric surgery, and the back part about appeas.

2- if you don't find bariatric surgery excluded, then read your appeal denial letter and find out exactly WHY you were denied.

3- figure out what it is that they say you are missing, or need to do, before you can get approved and do it.

4- appeal again.

Most policies allow three or four appeals, and each one is reviewed by someone different. good luck!

Cinderella

[Texasmom65 23]

Update: I appealed the decision through the Insurance Administration JUST to find out that MY insurance does not have to answer to them! I AM SO SAD! I don't know where or what to do and a lawyer is over a grand. Don't have that just sitting around for a MAYBE....lol. UGHHHHH!!!!!

What state do you live in?

[Puppylovemommy 8]

We have BCBS of Louisiana and our insurance excludes it completely. They don't even let you appeal it! So I'm going to Mexico nextt week and doing it!!! Have you considered this as an option?