So I Got Denied Today

[somaiswhat 29]

I'm in the process now and nothing was mentioned about being over 35..

[DreamsOfSkinny 53]

I'm in the process now and nothing was mentioned about being over 35..

Well that's great! My doc was supposed to have my peer to peer today but when I called his office they dont even know if he did it but said he wants me to come in tomorrow to talk. :-/ Hoping this means a Good thing..... But think maybe denied again and he's trying to figure out more info to find a way to get it approved

[somaiswhat 29]

Haha hearing all these denials is gettig me nervous now, I thought my process was going to easily!! I'd been referred by my prior PCP for a couple years to go to the bariatric center for weight management and I was finally ready this past October. Got into a program, and I have all my labwork, meeting with surgeon, and cardiologist to clear me for surgery, which they said was the final step. Told me my insurance requires me to lose 5 percent of my body weight before surgery, so I'm workig on that now, and had me sign a paper that said insurance requires me to be in the program for 3 months, which would mean in January I'd be eligible as long as I meet all my requirements..I'm worried now tho!!

[DreamsOfSkinny 53]

So update... I went to Dr. Today to find out my weights from my primary physician were never received by them and never given to my insurance, so mu insurance only had my weights after I had lost some lbs. for 2 out of the 5 years... I had to request those files to be faxed over gain today. Dr. Wanted me to write note with all these weights documented along with stating that the BMI the medical director said I am currently is inaccurate. He was puzzled how she even came to that number. I'm 5'2 and 220 which is 40.2 --- she had said I was denied because I wasn't currently over 40 and was 37.4. :-/ I called my insurance again and they gave me benefits criteria like I knew before and said I had to have my Dr. Send in information in to request a new peer to peer review since this one never happened. I then called my work and got a copy of the REAL criteria based off of my summary plan blah blah... It doesn't say anything about co-morbidities at all! It only states I need to be 40BMI currently. Show I've been "morbidly obese" for 5 years from physicians. Over 21. And go to in-network hospital.

I meet all of those once the insurance gets my correct weights for 2 years and gets weight for my 5th year. So, there should be no reason not to be approved now, but knowing how much of an issue it's been I think the ins. Is going to say morbidly obese is 40+bmi... I just feel it coming so I looked it up and many medical practices say bmi 35+ is morbidly obese.

I also called my job to tell them the issues I'm having with insurance giving me wrong information, denying me for inaccurate information on their part, not returning peer to peer calls, not sending me denial letter until 1 1/2 weeks later and then saying I only have 14 days to request peer to peer. My job has a 3rd party company that looks into all of this to make sure I'm receiving the care I need. Specialists should call me back Monday or Tuesday next week. Hopefully then all this bs can end and just approve me because I meet all criteria and we can all move on. Sad bc I work for such a Large company so I know they don't want their employees going through this with insurance.

I'll post back again...

I hope that this can help someone else. Don't give up or get discouraged.

[SkyPaw 2]

When you talk to your employer, who do you talk to? I'm a contractor, and have insurance through the contract company. Even though it's United HealthCare, they excluded bariatric surgery from being covered at all. Not sure who to call to see if I can get an exception, or what hoops I may need to jump through. I'm afraid our HR people really don't care, since I'm 'just' a contractor... but I don't want to give up this dream!

-Carol

[Piplula 709]

When you talk to your employer' date=' who do you talk to? I'm a contractor, and have insurance through the contract company. Even though it's United HealthCare, they excluded bariatric surgery from being covered at all. Not sure who to call to see if I can get an exception, or what hoops I may need to jump through. I'm afraid our HR people really don't care, since I'm 'just' a contractor... but I don't want to give up this dream!

-Carol[/quote']

Don't give up on the dream...I am not sure I would call it a dream...more of a goal...I think of dreams as nice things...this isn't nice...it's hard! I digress ...I know it's scary...but there are some Dr.'s patients on here that highly recommend Mexican doctors and actually stay in a facility longer after the surgery than I did....I got kicked out after 24hours and probably should/ wanted to stay longer. If you can afford it, maybe that is something you can research...there are plenty of people here that will offer you advice on it. In fact there is a forum on here dedicated to the subject! Check it out...don't give up on the goal! It's still within reach..

[DreamsOfSkinny 53]

When you talk to your employer' date=' who do you talk to? I'm a contractor, and have insurance through the contract company. Even though it's United HealthCare, they excluded bariatric surgery from being covered at all. Not sure who to call to see if I can get an exception, or what hoops I may need to jump through. I'm afraid our HR people really don't care, since I'm 'just' a contractor... but I don't want to give up this dream!

-Carol[/quote']

I have a copy of my summary plan description and it's covered.

[DreamsOfSkinny 53]

So peer to peer got denied. Medical Director said I don't have BMI of over 40 for last 5 years... Although the language of my plan states "morbid obese" for last 5 years.

When I googled this I saw many medical offices and studies say morbid obesity is 35+ BMI if the patient has co-morbidity.

Does anyone know where I could find some documentation the insurance company could use to support this claim?

[Heyher 581]

If the BMI requirements are 40+ then that is what they base the denial off of. That's what I am fighting too. It is so hard, but that is the policy that was chosen by the employer.

Now before you lose hope, submit your appeal to reverse the denial stating the medical necessity based off of whatever comorbidities you have. Have the surgeon note the diagnosis of those comorbidities. Also ask your primary care to write a letter of medical necessity based on those comorbidities.

Most insurance companies look for physician diagnosis of diabetes, sleep apnea, or high blood pressure. Those are the three main ones. But there are others that can help approval.

[Heyher 581]

When you talk to your employer' date=' who do you talk to? I'm a contractor, and have insurance through the contract company. Even though it's United HealthCare, they excluded bariatric surgery from being covered at all. Not sure who to call to see if I can get an exception, or what hoops I may need to jump through. I'm afraid our HR people really don't care, since I'm 'just' a contractor... but I don't want to give up this dream!

-Carol[/quote']

Try your state insurance board. You can appeal the exclusion. It may include lawyers and such, but that is an option.

Also Mexico is a great choice for those who can afford it.

[LaceSleeve 76]

Sorry to hear! But don't give up! I got approved at the beginning of the month after trying to get approved for 2 years. I have to do 2 behavioral assessments, 6 months supervised weight loss, 4 seminars, 2 dietary classes, had to get notes from 4 of my doctors saying they think surgery would help me, and had to meet with my weight loss counselor about 5 times. It was crazy but I stuck with it and in the end it paid off and I hope it does the same for you keep your head up.

[evelynvsg 136]

Dont give up!!!

[alabamaorthogirl 9]

So I called again and got ref. number for call stating that I only need 1 co-morbidity and bmi of 35+ for past 5 yrs although the medical Dir. Of Ins. Said I was denied bc I didnt have bmi of 40+. Second issue the insurance chose 2 of my lowest weights for 2 yrs and didnt even mark down for a whole year EVEN THOUGH my dr. Submitted all health documents! I talked to my ins. Coordinator at Dr office today

[alabamaorthogirl 9]

So I called again and got ref. number for call stating that I only need 1 co-morbidity and bmi of 35+ for past 5 yrs although the medical Dir. Of Ins. Said I was denied bc I didnt have bmi of 40+. Second issue the insurance chose 2 of my lowest weights for 2 yrs and didnt even mark down for a whole year EVEN THOUGH my dr. Submitted all health documents! I talked to my ins. Coordinator at Dr office today

[alabamaorthogirl 9]

That is why I got my records sent to me, then I picked the records to give to surgeon. The insurance lady told me she is suppose to pick the lowest weights. So, I took that out of her hands. I think the big comorbidities they are looking for are hypertension on meds, diabetes, and sleep apnea. I hope you get approved soon