denied last minute

[beesam 0]

I'm crushed!! I've gone thru 4 mos. of behavioral classes, lectures, physicals, psychs, and pre-op tests have all been completed, and two weeks before my surgery bcbsMA denied me because of medically necessity. Letter of intent sent to them in early October, and denial just came thru after completing entire program!! I have a bmi of 36, with hbp, cholesterol, possible sleep apnea, (sleep test pending). I just don't understand on what basis I can appeal this decision as a lay person. My surgeon's program secretary said the appeal is my job. Anyone have this experience? To get this far and have it end just like that is too much.

[beachgirl 2]

I was denied by them too and was self pay in Mexico. If I was use I would file an appeal. You have the comorbities as I did but I just didn't want to keep waiting is the only reason I did the self pay. If you don't mind waiting I would fight them. Good luck and let us know how things go.

[Lap_dancer 8]

I have BC/BS of Florida and I was told that it is not a covered benefit. HOWEVER, there is a requirement of insurance that they pay for a procedure if your physician deems it medically necessary(MN). That MN must be proven by documentation such as lab results, other doctor's supporting letters indicating your condition (like a cardiologist who says you have high blood pressure etc.,) That's how it is in Florida.

Right now I have gone through all of this. Before I even began the process (Sept.) my doctor, who recommended the Lap Band surgery, sent me to the hospital where it is performed. They gave me a folder with a list of documentation you will need ( most of all you said in your post Beesam ) Before I even began the tests, I called my insurance company. I told them my BMI ( 58) and that I am a diabetic and so on and so on and so on. My question was am I going to go through all of this for you all to tell me no? What I was told was that everything must be documented. In medically necessary situations, your request goes before a review board in the pre-certification department. Based on all of that information, they authorize the request. If I were you, I would ask WHY they said no and to please put it in writing. If you have the letter already, begin the appeals process. You have 30 days.

Sometimes what we want never comes easy. Sometimes there is a fight in the process. Don't give up quickly. All you have to lose is weight and a stamp and possibly time. Don't be discouraged, I know that is hard right now. I am waiting for the NO for the lapband despite my doctor sending in a letter already as well as the pulmonary doctor and cardiologist. I'm still waiting for them to tell me NO when it comes right down to the surgery date. But they approved the surgeons office visit for presurgery and they have approved all tests. I am still poised for a fight.

I'm new here and it's odd this is my first post on here and I'm responding to you B. I'm with you! Let me know your outcome.

[Ariel 1]

which hospital are you going to? I'm at brigham and womens and during the seminar the financil adivor said if any one got denied they would work with them. I'm sorry to hear that they denied you last minute that it pretty bad. Goodluck with the appeal.

[beesam 0]

thanks so much for the support. I'm waiting for everyone to come back from holiday weekend to start pounding away at whatever I can to get this done.