peer to peer review

[lisahg 9]

Hey Folks,

I just found out this morning that Highmark (Pa.) BCBS has denied by request for VSG . Apparently their medical policy requires a BMI greater than 50 and VSG as a 1st stage in a two stage procedure. My BMI is 37 with 2 comorbidities, I plan to appeal with a letter and substantiated research articles. My surgeon's coordinator says the surgeon will do a peer to peer review next week. For those of you who have gone through this, are peer to peer reviews typically successful in getting the insurance decision reversed?

Thanks

Lisa

[MsSlim 0]

I'm still a newbie at all this so I can't speak from experience but wanted to ensure that you were aware that the FDI earlier this year (around Feb) lowered the criteria for the guidelines for lapband to a BMI of 30 with comorbidities. I know that's not the same procedure but I think an argument could be made. The standard for the industry even prior to this decision seems to be BMI of 40 or 35 with comorbidities. I hope all goes well for you.