confused about the approval process

[MsMe 22]

Has anyone been approved by Anthem Blue Cross with a 35 BMI, sleep apnea, high cholesterol, & pre-diabetic? My paperwork was turned in for approval a week ago & I haven't heard back yet. My doctor said he could always appeal it if I'm denied.

[MsMe 22]

I just got the call I was denied.

[dede0314 356]

@@MsMe What was the reason for denial? Appeal until you can't anymore. I was denied three times until I was finally approved.

[MsMe 22]

They said my BMI was too low with no comorbidity. I had the sleep apnea but nothing else they considered severe. My doctors office is going to try & appeal it, but my insurance changes to Blue Shield starting Dec 1st. My doctor's office said they aren't confident they can complete the appeal in time. I will need to apply to Blue Shield next & I think they have stricter requirements. I'm not really sure. I'm so devastated! I just don't know what to think or do.

[2goldengirl 2,076]

MsMe, you are incorrect, look at the posts above, Blue Shield actually has easier criteria.

However, with a BMI of 35, that's right on the brink of being too low.

Anyone who has a Clifornia HMO plan can get their health plan's criteria for the surgery (or anything else) in writing on request. Most of them are available online, just Google your health plan name and the kind of procedure.

In some cases, (again, in CA, HMO coverage), your medical group may have their own guidelines. In that case, be armed with your health plan's criteria. Usually if you point out that your health plan uses different criteria, they will use the plan criteria. This is because the plan will overturn on appeal a decision that doesn't conform to their criteria.

[Trinn 139]

Yes, as of this summer, Blue Shield has much easier requirements above a certain BMI, but below it, they appear to still be cautious. However, because of their new "No strict guidelines", they say they are being more flexible. It was certainly my experience -- I went from first consult/info session to approval in 2.5 months. And BS's response on the pre-auth is 5 days. That's their policy now -- you get an answer back in 5 days.