Blue Shield Denial - so upset

[Breesmom813 0]

Hi All. I started the process in January of getting everything together for gastric sleeve surgery. The surgeons office have me a list of things I needed to do I.e. X-rays, blood tests, psych Eval, EKG, visits with dietician, etc. I was told I needed to see the dietician until she thought I was ready and needed to lose 15 lbs. I saw her in feb, march, had to reschedule April and may and saw her again in June and July at which time she signed me off.

Finally 2 weeks ago I had my sleep apnea study complete and all was sent to insurance.

I got denied because I didn't have "6 consecutive months of medically supervised weight loss program"!!! NOBODY told me I needed that. I even called my insurance back in January and all they said was it would be coveted if deemed medically necessary by physicians.

I'm so upset. If I had known it had to be consecutive of course I would have gone every month! I kept a food diary and everything but had no idea it had to be 6 months.

Any advice?? Do you think they will actually make me start over with 6 more months??

My BMI is 46, I have type 2 diabetes, high blood pressure, moderate sleep apnea, and I'm only 32. I am so ready for this surgery and I just keep crying because this seems so unfair. Nobody told me this throughout this whole process

Help !

[kathp 81]

Yep, they'll make you do six consecutive months.

You can start over from whatever point you are consecutive. My surgeon's office warned me about this, and I'm surprised yours didn't. Your sleep study and everything is good for up to a year, so you'll be good. Can you quick get in for August so you'll be three months done?

[ReadyNewM3 112]

Im so sad for you....sorry. Appeal?

[Breesmom813 0]

No they never told me and I asked multiple times. They only said I needed approval from the dietician that I was ready! I'm out of town and won't be back until next week when it will be September! . This seems so unfair! So now I won't be able to resubmit until March. I just can't believe this.

[Ms skinniness 3,003]

Have you done weight watchers or anything? Can you talk with your PCP and ask him/her if they can help you with this......If not, I'd appeal it, but meanwhile, perhaps go to a weight watcher's meeting in the area you are at just for documentation. It doesn't hurt and can save you some time.

[Breesmom813 0]

I'm going to file a grievance, I'm just not sure how lenient they are. It makes me sad that its 6

More months of not having energy to play with my 2 year old daughter the way she deserves to have a parent play with her. I've done WW a few times in my life. I try it all, and fail.

[LipstickLady 25,682]

I know it's disappointing, but they are not lenient at all. Start your 6 months while you file and hope for the best, but prepare for a 6 month wait.

[Ms skinniness 3,003]

I'm going to file a grievance, I'm just not sure how lenient they are. It makes me sad that its 6

More months of not having energy to play with my 2 year old daughter the way she deserves to have a parent play with her. I've done WW a few times in my life. I try it all, and fail.

WW has been accepted by some insurance companies for monitoring weight......

[FRED1977 186]

I hate when I hear these stories of how big brother insurance companies sit on their fat wallet s,we pay them money every month or pay period and never cheat them out of their money. Here is someone that has a medical need for wls,and is getting flushed down the scapegoat bs. If your BMI is that high and not to mention the diabetes is dangerous enough. If you have wls your health will increase and then you won't have to be on a supervised wl program. You wouldn't be needing surgery if you could control your weight . I hope you get your surgery and you are able to feel better soon. good luck to you,stay focused.

[Dons2.0 39]

I'm so sorry to hear this. It's sad that you miss out and suffer because you were misinformed! If I was you I would appeal and appeal until they are sick of hearing from you!

Prayers are with you and fingers crossed they will do the right thing! Good luck! Xo

[beauty29 72]

I did weight watchers and just got approved

[youthguy80 65]

They usually want six months consecutively of your PcP documenting your attempts. I had TWO YEARS of a supervised nutrition and exercise program. Had two years of notes showing my PCP was medically supervising. I was denied because I didn't have 6 in 6 consecutive months. I even appealed and was denied. I know it's frustrating. Just stay focused on the end result and use the time with your primary to work through a lot of the mental stuff. And start making lifestyle changes now---cutting out carbonated beverages, weaning off caffeine and fried foods, etc.

Also, get your medical policy from insurance regarding weight loss surgery (mine was under "obesity") and know it front and back.

I hope these months are helpful and go by quicker than you realize.

[beauty29 72]

It really all depends on your insurance. I have UHC and my doctors admin swore up and down that I would be denied because my 6 months were not consecutive and I didn't get denied.. UHC has Bariatric resource Center and those people help you to get approved by telling you exactly what you need. They tell you what you can do and can't do

[nyorker 67]

Your surgeons office dropped the ball. The first thing they do is give you a list of things to do and you primary Dr to have you on a supervised diet. Like 1200 calories a day and exercise. Visit the Dr once a month and Dr writes sane thing and of course weight. If lost or gained.

Of course we dont follow it because we want the surgery and the insurance to say yes.

In the end the Dr gives nots ti surgeons office and it is faxed with everything for approval. It seems the surgeons office screwed up how can they be that stupid?

[Sydney Susan 333]

I really feel for you - health insurance doesn't work this way in Australia (if your specialist surgeon or physician says you need a procedure that is the end of the discussion, your health insurance either covers that procedure for everyone or doesn't), but perhaps we pay more for insurance. At the best of times US insurance companies sound pretty mean to my Aussie ears.

In this instance the OP has a high BMI and serious co-morbidities, and is the mother of a young child. She seems an appropriate candidate for this surgery, but even more so her health is being endangered by the insurance company arbitrarily withholding medical care for her. Don't these companies have any liability if something happens to a patient while jumping through the insurance company's hoops? Esp as the patients PCP and surgeon have both recommended this surgery for her???

Appeal, appeal, appeal just has to be the answer - and while doing so follow their silly procedures but keep pointing out the risks you are being needlessly exposed to. Go to the local papers and lay out your story just as you have here. Surely people would be up in arms about this sort of stuff. Wouldn't they???