BCBS Federal Denial. Anyone appealed?

[college_chick 20]

I got the news yesterday that I was denied. On 3 of my weights from 2011 I clocked in with a BMI of 38.94, 38.1, and 39.1 with no comorbidities. Every other date I met the 40 and above requirement.

I'm hoping to appeal this somehow and I'm waiting on my insurance coordinator to get back with me on how to proceed, but I was hoping people on here might be able to help point me in the right direction. The date of the 39.1 BMI was in October. Would I have to wait past October of this year and resubmit so that my years would be 2012 and 2013?

Thanks for any and all help!

[Staci27 31]

I have Blue Cross Blue Shields Federal PPO Standard, I have the lapband, so I am getting a revision from Band to Sleeve. I was denied on my first letter, but they request for me to do a 3 month program with my PCP, 1 nutionist visit, 1 physc. eval.. I was approved after resubmittal of paper work with all of the clearance from PCP, nutrionist and physc. My surgery is scheduled on 28 May. So I hope this helps, but you can do an appeal. Are you going for your first weight loss surgery?

[college_chick 20]

Yes this is my first procedure. I did all of the requirements (3 months of visits, psych eval, nut appt. etc) They are denying me because for 3 weight out of 2 years my BMI was not 40+. I was on phentermine at the time attempting to lose weight. I guess I feel like I'm being punished for trying to lose weight.

[SpaceDust 585]

Yes this is my first procedure. I did all of the requirements (3 months of visits' date=' psych eval, nut appt. etc) They are denying me because for 3 weight out of 2 years my BMI was not 40+. I was on phentermine at the time attempting to lose weight. I guess I feel like I'm being punished for trying to lose weight.[/quote']

I would definitely appeal. Make sure that you explain that the three months which were below 40 were during a weight loss attempt which clearly ultimately failed.

Does your surgeon's office have an insurance coordinator? They could probably assist you in understanding how to proceed.

Sent from my SAMSUNG-SGH-T989 using VST

[college_chick 20]

Yea I got a hold of her today. She said I'd have to write a letter and get a letter from the Dr. that prescribed everything. But its in my charts that were sent over that I was taking adipex (my insurance coordinator read it to me over the phone) so idk why I have to have the Dr. sign too but... Whatever helps me get this surgery.

[ItsFinallyMyTime 5]

I am in the same situation. I have submitted for approval but fearing a denial because my weights in 2011 were only 38 and 39 BMI because I had gone thru a divorce and was living alone and had a short success at a new diet, but ultimately I ALWAYS gain it all back and am now once again 41 and 42 BMI. Have been my whole life except on the tail end of a ahrd diet and then the slow rise back up...I have Aetna POS CHoice II I did get a letter from my doctor listing higher weights prior to 2011 - but they are not documented on anything but his letterhead. I did not have insurance before 2010 as I have been self employed and healthy- almost never going to a doctor - Im very homeopathic.. I still have hope and am praying the letter does it!!! I hope you find a remedy too.... It is awful to feel like we are punished for having temporary success on a diet!!!!!

[college_chick 20]

Exactly! Especially since you have to prove that previous dieting attempts weren't successful. Well uh duh! Here's your proof insurance! I went from 230 to 260 in less than 6 months I'd say that's a fail.

[ItsFinallyMyTime 5]

@College_Chick, My weight situation is very similar. Is it right at BMI 40 ish... but had yoyo success over past few years and am pretty healthy so no real medical documentation except when I was at a low point of weight. I got a letter from my doctor in which he listed.the highest weights I have been for the past 6 years (information I had to tell him because I have only been seeing him for 3 yrs) He wrote my basic info... years and high weight for each year on his letter head and that is what we submitted and got approved... It bypassed the low weights and just listed the high weights of each year... It may be worth a try... AETNA accepted it.

[college_chick 20]

I have to write a letter that explains that I was on phentermine at the time. So hopefully that works.