???? insurance denied

[tiffy122004 2]

Hi all. Well my dr just called and stated that my surgery was denied stating I don't meet the criteria. My dr is going to appeal upon my behalf, in 2011 I had spine fusion because I have degenerative disc. No trauma just genetic. U haven't had a bit if back pain until gaining 60 lbs and now the pain is back. Has anyone been denied and them approved. My dr seems to think we have a good shot. But I am still nervous and frustrated.

[kwilli8 8]

I am a RN Case Manager at a large health insurance company. I personally review and approve Bariatric surgery in addition to having a bypass myself on Sept 17th. There is medical policy that clearly has to be met. Most importantly a BMI > 40 or BMI of 35 to 39 with diabetes, high blood pressure, sleep apnea, etc. Go online or call your insurance company and ask for a copy of the medical policy.

[tiffy122004 2]

Thanks for the response.

It clearly states that degenerative disc is a co morbidity. I have a 2 year old lil girl that is running laps around me. I need the surgery to help give me a push to change my life style forever. The spine fusion in 2011 changed my life forever. I never felt that pain again until recently. I hope I can get a letter of recommendation from my neurosurgeon, and I also have Graves' disease which is a thyroid disorder. Just diagnosed a year ago which was when the weight just piled on!! Do you have any other advise for me!??

[ready2B 263]

Hi - I wasn't denied for my WLS but have been for other things in the past and found that perseverance can pay off. Keep the conversation open with the insurance company. Have your doctor intercede as much as he/she can. Write letters, make phone calls. Sometimes it took me three appeals to finally get approved for something. Usually it is when I could prove that in the long run it would save the insurance company a lot of money if they allowed me to have a specific treatment, then they were more willing to approve. Their bottom line was/is more important to them than my quality of life so I had to make it about the money they would save. Insurance companies are not in the business of improving our quality of life. It is all about financial investment for them so if you can take that approach, you might be more successful. Also, I got my husband's HR department involved too since the insurance was through his company so they had the ability to make exceptions. Don't give up until you've exhausted every possible avenue for appeal.