Do I Have Any Chance With This Gastric Sleeve Appeal?

[lisahg 9]

Hey Everyone,

About a week ago, I was denied by Highmark BCBS for the sleeve based on it not being medically necessary and appropriate. My BMI is 36.4 with associated Hypertension and Type 2 Diabetes Mellitus. My surgeon did a peer-to-peer review this week but got no where with the physician on the review committee. Based on the fact that the peer review didnt make any progress, what are the chances that my appeal letter will have the denial overturned? I am kind of bummed because I think my chances are not so good now.

Thanks

Lisa

[Fusilli66 22]

I have to say that things like this just piss me off and scare me at the same time. I know every insurance company is different, but you have 2 co-morbities and your BMI is over 35 - how dare they deny you. I would certainly try appealing - it seems like you should qualify - but I don't know what the requirements are for your insurance.

I hope it works out for you - I haven't gotten that far yet. I am hoping that they will be sending in my paperwork on Monday as by then they should have everything they need. My BMI is 39.9 and I have sleep apnea so we will see if I get approved.

Good luck to you!

[lisahg 9]

Thanks for your reply and support! It is pretty discouragning to have done all the prelim. stuff and then get denied. Apparently there is a stipulation with my bcbs that you have to have a bmi of at least 50 to qualify for the sleeve. I didnt realize this when I first started this process but I still dont plan to go with the band or bypass. As a result of doing research for my appeal letter, I learned that the vsg was historically performed at the first in a 2-stage bariatric surgery (the 2nd being the roux-en-y or bd switch) for people with a bmi over 50 that are high risk. So my insurance hasnt updated their knowledge on the sleeve and its benefits for lower bmi people. I hope things go smoothly for you.

Lisa

[MelissaAnd 3]

Oh! That's awful! I had to fight to get mine too! I had sleep apnea, acid reflux and high blood pressure with a BMI of 38. They denied me at first. I had to get several letters from all of my doctors in support of the procedure. My sleep doctor even wrote a letter stating that even though my BMI was not at the required 40 that I needed a large amount of pressure to alleviate my tendency towards sleep apnea. The insurance company tried to say my sleep apnea wasn't severe enough. The fact was that I would stop breathing while sleeping. It doesn't take a genius to realize that when you are not breathing, you are at risk of dying!

It took me about 4 months of fighting, but I was finally able to win. I also ate more and drank a lot of Water before my weigh in. I had to put on about 15 lbs of weight to get the insurance company to finally approve me. It was not an easy win, but I wouldn't give up!

Insurance companies are in the business to make money and if they deny you, they are making money on your premiums without having to pay out for services. So, fight for your life and get your doctors to write letters in support of the surgery. Hopefully, one of them will update their knowledge on the benefits of the VSG and help you win your appeal!

[AngiL 0]

Hey Everyone,

About a week ago, I was denied by Highmark BCBS for the sleeve based on it not being medically necessary and appropriate. My BMI is 36.4 with associated Hypertension and Type 2 Diabetes Mellitus. My surgeon did a peer-to-peer review this week but got no where with the physician on the review committee. Based on the fact that the peer review didnt make any progress, what are the chances that my appeal letter will have the denial overturned? I am kind of bummed because I think my chances are not so good now.

Thanks

Lisa

I will look to see how you made out. My daughter is also waiting an appeal. She has a BMI of 44 and one CoMorbidity and Highmark denied the precertification. We are awaiting an expedited appeal for her and should hear within the next three days. Her surgeon did not seem too hopeful that it will be overturned but we are seriously praying. We will pray that yours is reversed as well. I have not found anyone that Highmark has actually approved, seems that they are behind the times with procedures.

Take care

[lisahg 9]

I will look to see how you made out. My daughter is also waiting an appeal. She has a BMI of 44 and one CoMorbidity and Highmark denied the precertification. We are awaiting an expedited appeal for her and should hear within the next three days. Her surgeon did not seem too hopeful that it will be overturned but we are seriously praying. We will pray that yours is reversed as well. I have not found anyone that Highmark has actually approved, seems that they are behind the times with procedures.

Take care

I am still waiting to hear, Highmark has had my appeal for 2 weeks and they have up to 30 days to respond. I am glad to hear that your daughter got an expedited appeal. Have you gotten a decision yet? If I am denied again, I plan to move ahead with an indepedent external review through the state (not sure of the proper name for that) of my case. Good luck to everyone dealing with their insurance.

[legnarevocrednu 47]

_{Just found out today that Highmark BCBS denied me for being under 50BMI as well. Wish I had known this. Wish my DOCTORS had known this. What the heck. Now I'm getting the lapband. Sucks!!!!}

[2bfit 62]

I went through an appeal with UHC H M O. My insurance covers the sleeve and I did eventually win my appeal. The only thing I can tell you is if you really want this you HAVE to fight for it. Nobody else will do it for you. The girls in my surgeons office did nothing to help me with my appeal. You are going to have to be your own advocate and you are worth it. Unfortunately, if they do not cover the sleeve you can't fight that but you could get approved for whatever other procedure they cover.

I did a little research and came up with this link:

https://weightloss.clevelandclinic.org/images/file/Insurance%20PDFs/HIGHMARK%20BCBS.pdf

I highly recommend that you read this and use their policy against them in your appeal and you should also send them a copy of their policy with your appeal (I would recommend you get a copy of your specific plan sent to you in writing, I just used the link above based on the Highmark BCBS which may not match your plan exactly).You have to write an appeal letter that documents everything you have done on your own. You also should gather as much documentation as you can get your hands on to support your claim that this is medically necessary. You have to get your medical records to prove your comorbs. You also have to show proof of the medically supervised diet you have been on. You literally have to blind them with paperwork. They want you to give up.

In your appeal letter you need to also reference the NIH guidelines on obesity and send a copy of it with your appeal letter. You should also reference how being obese has affected your life, your daily challenges etc.

If you send me your email by private message I will be happy to send you a copy of the appeal letter I used.

Please do not give up! Your life is on the line here. Do not let them take that from you!

Good luck!

Cheri

[2bfit 62]

Disregard the previous link. This is the most current guideline for Highmark:

https://secure.highmark.com/ldap/medicalpolicy/wpa-highmark/G-24-035.html

[AngiL 0]

Update -My daughter did have surgery. Her second appeal was denied but the company I work at and my benefits department helped me greatly as my company is self insured. I also found out that Highmark covered the surgery for other patients with a BMI less than 50. Don't give up, I know how much it sucks and how heart breaking it is but it is worth it in the long run. My daughter is 8 weeks post op and has lost 45 pounds so far. It is like she is a new person already, much happier. I am so glad we did not switch procedures and go to the Lap Band. I don't know that she would have the best results with that. We probably would have gone with a Roux en Y if she would not have gotten approved for the sleeve. Good luck everyone

[lisahg 9]

Hi All

I am so excited to report that I have been finally approved for the sleeve through Highmark BCBS! I was initially denied in August, appealed and denied again. I then filed an external appeal through an independent review organization and finally found out today that they overturened Highmarks decision. Yay! I did mega research in writing my appeal letters to substantiate my case, but it was worth it. I can wait until tomorrow to call the surgical coordinator to see when I can have a surgery date.

Lisa

[BenisaMartim4 369]

Yay for you! I am so proud. My insurance is dragging their feet. I am so afraid they are going to deny me for some reason. I meet all of their requirements, but may have missed jumping through one of their loops. My BMI is 49.8, so I am way over their 40% + I have co-morbidities too. My medical bills have been $30,000 in the last 5 months. You would think they would thank me for having it done, but no. They want to jerk me around and keep my nerves torn up and make me cry. I just want to scream!

[Mommali 0]

I have been denied due to having a 40 BMI but not having the approved medical reasons I have high blood pressure but it isn't high enough nor my chlorestrol, both my parents have high blood pressure, diabetes, sleep apnea, and high chlorestrol so I was hoping to nip it in the bid before I got bad but I got denied my doctor is gonna try the peer to peer and if not appeal it but does anyone think I will have a chance, it majorly sucks I payed all the money and did all the requirements to be approved and get denied

[longer-life 139]

Hi All

I am so excited to report that I have been finally approved for the sleeve through Highmark BCBS! I was initially denied in August, appealed and denied again. I then filed an external appeal through an independent review organization and finally found out today that they overturened Highmarks decision. Yay! I did mega research in writing my appeal letters to substantiate my case, but it was worth it. I can wait until tomorrow to call the surgical coordinator to see when I can have a surgery date.

Lisa

How exciting!!!! Congratulations!! Your persistence paid off! You kicked Highmarks bottom!!!! :boxing:

Please consider writing a long post about your journey on the "health insurance" forum. It will help a lot of people! You are amazing!!!!!

[Bamabander 111]

Hey Lisa!

Congrats on your approval! I am in my last month of my 6 months and satisfy all other criteria. I also have Highmark BCBS and really want the sleeve but BMI is 37, sleep apnea, joint problems... I am afraid to request it and am wondering if I should just do the regular bypass... any information you can give would help. How long was your appeal letter and what specifically did you cite? Just not sure what to do because I just want to get going... I hate thinking they will deny me!