Denied Blue Shield Of California (Ppo)

[helleva 22]

I have received my letter of denial today. It states the a Medical director has reviewed my request and has denied it because "The documentation does not demonstrate significant obesity-related complications (comorbidities) which have failed to be controlled with medical management."

I am really disappointed. My coordinator swore i would be approved because I had gestational diabetes, i have one kidney due to donating it to my father who has diabetes, kidney failure, rhinoplasty (spelled wrong but he can go blind from diabetes), high blood pressure, quadruple bypass, and some, and I was diagnosed with sleep apnea. I am so scared because all diets have failed even though i try so hard. I have three beautiful little girls, ages 14, 11, and 1 and i fear that i am following my dads footsteps.

I talked to the coordinator and she states i should have been approved. She states although the sleep study was included in the paperwork that my doctor did not note it in his letter. He did not state that i had Sleep Apnea and now use the CPAP machine. I hope this is why i didn't get approved. My coordinator is going to try and set up a peer to peer review. If this does not work she is going to try an appeal.

I have made a doctor's appointment this Tuesday with primary because i believe that I also have GERD (have all the symptoms).. Do you know if GERD can help me get approved if i do have it? What if I ask my primary to write me a letter of recommendation? or ask my last doctor who I went to for ten years to write me a letter of my struggles of weight?

I am looking at Obesity all my life (bmi just under 40), gestational diabetes, mild case of sleep apnea, possibly GERD, one kidney, and family history of diabetes, arthritis, high blood pressure, kidney failure.

thanks fpr your help and support,

Denise

[Formerly Fluffy 5]

Appeal! There is an appeal sample letter here:

http://www.formerlyfluffy.com/bariatric-surgery-insurance-appeal/

Also you might give them a call at OAC and see what they suggest:

(813) 872-7835

[Bubbaloo10 55]

Documentation is the key. If the documentation was not submitted by your coordinator prior to submittal this is her fault, not yours. I would think you have more than enough history to warrant the surgery. Get back to your coordinator, get her to pile up the documentation and drop it on them...you're sure to be approved...Good luck

[MinaT 669]

sleep apnea, high blood pressure and pre-diabetic after having gestational diabetes is three comorbidities. The GERD isn't considered a comorbidity and actually after the sleeve it could exacerbate it if you eat the wrong things, so this is something you will need to know up front.

The doctor can shoot off another quick letter relisting the the sleep apnea documentation and they can again reiterate there are 3 real comorbidities and it should be an easy decision. If not you are allowed to appeal and the office can get it right the second go round.

Best of Luck and I hope you hear back soon.

[ProudGrammy 8,322]

Denise

hi there

IMO, having donated a kidney, plus your other morbidites should qualify. sleep apnea, The obvious complications from having one kidney and being obese must show a problem in itself..

Isn't the whole reason for WLS to be approved in the end - is because having the WLS in the long run deals with all those medical problems in the end - saving insurance companies money in the long run. all though we need it for our heath improvements.

We all know the above, people medical with problem, and obesity is one of our big problem.

i'm just so upset about people being denied when then desere it

the WLS- its not we are 20 lbs overweight, and want to look skinnier. - there are serios reaons for WLS.

frustrated

hate insurane companies

APPEAL , APPEAL,APPEAL

btw - how great of you for donating your kidney to your dad

i was approved immediiately by BSBS but i'm still angry about the above, mainly venting here

kathy

[helleva 22]

thank you Formely FLuffy,

I will definitely look into the info you gave me.

THanks Bubbaloo10,

I hope that it was my coordinators fault. I was working with this one lady the whole time and just before my paperwork submission she left to have surgery and was out for two weeks. She left the paperwork to be submitted by another lady. I'm hoping my original coordinator will be back this week so that she can over look it and re-submit to my insurance.

Thanks Minat,

I was reading about GERD and how it can be linked to obesity. I asked my coordinator if I was diagnosed with GERD could it possibly help my chances of getting approved. She did state that anything at this point will help. I thought it would be an easy decision because of all of the above ^^ but my insurance company seems to think differently. I'm assuming they believe I don't have cormorbidities that my father has yet.. and when I do get them (which i am at my weight) that i will no longer be their problem and another insurance company's problem.

thanks Likesulema,

oh do i hear you! I am so frustrated. I really thought i'd be approved first time around. I just like I'm sure many have struggled my whole life with obesity. I don't care to wear a bikini and look like a model. I just want to live a healthy life and live long enough to raise my 1 year old and possibly see my grandkids one day. I hope and pray that my insurance will approve my surgery with the peer to peer or the appeal. Thank you for the compliment of donating my kidney to my dad. but it wasn't a choice.. it was a must.. I NEED him

I greatly appreciate all of your responses and information in trying to help my situation all you great folks really help ME and you give me so much hope reading your success stories from insurance to your new life after the sleeve!

Denise

[mmorral 19]

Denise,

I am sorry to hear about the trouble you are having with the insurance. I too have Blue Cross PPO. I know that one of the things that they a strictler about is the BMI. You mentioned that you were just under 40. From when I went through the process I had to be over 40 for a while.

Just a few suggestions... see if the doctor can re-weigh you after drinking a lot of Water to get you at a BMI of 40 and to re-write it to put your sleep apena in the request.

If all else fails.. Appeal, Appeal, Appeal!!

[helleva 22]

thanks mmoral,

that's a great idea. but my only problem is that I've been walking everyday because i thought i was gonna get approved. i read that losing some weight before surgey is a great idea to shrink the liver and so forth. If i am weighed again i will be even less (about 8 pounds) I'm so stressed! haha! maybe i should sew some weights into my waist band?! jk. i just wish my insurance would see the benefits of granting me the sleeve. better, longer life for me & less money for them to spend later!

[valdostaGA 149]

There needs to be a foundation for things just like this. For people that need surgery and don't have insurance or no coverage. This is something I plan to look into. I want a non profit organization just for weightloss surgeries. This post upsets me! She has one kidney, highblood pressure, sleep apnea OMG what else do she need! I pray that u appeal this! This is very upsetting!!

[Formerly Fluffy 5]

There needs to be a foundation for things just like this. For people that need surgery and don't have insurance or no coverage. This is something I plan to look into. I want a non profit organization just for weightloss surgeries. This post upsets me! She has one kidney, highblood pressure, sleep apnea OMG what else do she need! I pray that u appeal this! This is very upsetting!!

There is. but it's a very new organization and there have been just a few surgeries funded so far.

http://wlsfa.org/

[helleva 22]

ValdostaGA,

Thanks for understanding my pain and frustration. I will be on top of my coordinator and insurance. A foundation would be awesome. Good idea <3 I see that our friend has found a link to one. If my insurance fails me I will look into it as well. I will fight to the end. Thanks for your prayer because in the end it is in gods hands <3

[helleva 22]

Formely fluffy,

Good looking out I am surely going to look in the foundation! You never know they might just be able to help me thanks so much for the link!

[helleva 22]

Woohoo! I am approved! First date was July 19th. Final date: July 24th @12pm.

Thank you all for your support

Denise ♡

[helleva 22]

Woohoo! I am approved! First date was July 19th. Final date: July 24th @12pm.

Thank you all for your support

Denise ♡

[Texas89 8]

Congrats......about tyme...ive been reading your posts and started to think what if i get denied too...you getting approved gives me hope on my approval... (: