DENIED...help!

[bncbabe2015 11]

So here's the deal. At my first appointment back in March, I was told by my doctors office that my insurance requires me lose 10% of my starting weight. So, of course I tried my hardest on my diet and lost the necessary weight.

Submitted to insurance Monday and yesterday I was told that I was denied by my insurance company because I lost weight on the 6 month diet, which means that surgery is not "medically necessary" for me to lose weight.

How can they tell you to do something and then deny you because you done what they ask?!

My insurance coordinator was FURIOUS and said my surgeon would be as well. They were going to try to set up a peer to peer conference with the medical director that was over my case and my surgeon.

Opinions, please?!

[The Candidate 3,215]

It's such a double standard. I also had to lose 10% and ended up losing more. Went from a 45 BMI to a 39 BMI before approval. But in my case, and I think in most insurance's cases, they count the BMI you started with, that you qualified to enter the program, not the ending BMI.

When I got down to a 40 BMI during the program I called and asked specifically if I would be penalized for going lower, and thus jeopardize my approval. She told me "no" and encouraged me to lose more.

You should appeal. I hope you eventually get your approval.

Edited October 1, 2015 by The Post Op

[bncbabe2015 11]

They did use my initial weight and BMI. But because I lost during the 6 months, they said I can lose weight on my own so it's not a necessary surgery. But they told me I had to lose during?! I'm so confused and annoyed. We are appealing. My surgery date is set for October 19th. Preop diet starting this coming Monday. I hope I don't get majorly set back. ????

[The Candidate 3,215]

That's ridiculous. I've never heard of something like that. Didn't they require past diet history to prove that yes, you can lose it, but you gain it back again. Like all of us have. Honestly I've never heard of something like that. I'd fight it!

[bncbabe2015 11]

Oh I am!

My surgeon will fight it, hard. They said its not right at all. I don't know how they can do that. I was so upset then the anger sat in. And now I'm furious! At least deny me for something else if you're going to, not for something you said had to be done!

[LadyK44 263]

That doesn't make any sense! The 6 months are traditionally used to test your commitment to the process. People are often denied because they don't lose weight. Fight!

Edited October 1, 2015 by LadyK44

[garseesmarie 3]

That is terrible! So sorry you're going through this. May I ask what insurance company you use?

[bncbabe2015 11]

I have anthem blue cross blue shield.

[Jefferyc79 103]

This is madness!!!! I have Blue Cross Blue Shield PPO. The insurance lady who is in contact with my insurance company has told me numerous of times that the insurance counts your HIGHEST BMI at any point you are in the program. Before I even started the program I reached out to my insurance company and requested them to send me Bariatric insurance requirements. If your BMI is over 50 your 6 month diet is waived. If your BMI is over 40 and you have other obesity related health issues like High Blood pressure, sleep Apnea, or joint disease you are eligible for the surgery. I have sense lost weight since my initial weigh in of 342 pounds (down to 316) my insurance better not deny me when they set the requirement. That's insane. Please fight this. They are so wrong for this. Keep us posted on this for sure.

[newmebithebypass 713]

Wow I've never heard of this happening that's bull shit

[bncbabe2015 11]

Yeah I know.

It's just so unreal. I don't want to get discouraged but it's hard not to. My surgery is supposed to be October 19 and I'm supposed to start preop diet Monday.

I'm calling tomorrow evening to see if my surgeon had the peer to peer meeting with the medical advisor at my insurance company.

[cheri02 14]

Please keep us posted. I have Independent Blue Cross Blue Shield. Every time I called to request information regarding the 6 month monitored diet, I never got a straight answer.

[bncbabe2015 11]

Every time I called I was told something different. They couldn't send me the qualifications in writing. One person would read it to me while the other would say, it's case by case and it's all dependent on if it's medically necessary.

[cheri02 14]

@@bncbabe2015, that was pretty much my experience too. I finally decided to just take one step at a time to see how things unfold. I truly hope things work out for you!

[bncbabe2015 11]

Hello all! I know it's been a few months. But after all that happened, we won the appeal. 2 days after winning the appeal, I had to reapply for Medicaid. I missed the income cutoff by $20 a month, therefore I was suspended and no longer receive Medicaid. I was devastated! I gained 10 lbs within 2 months. All I did was eat.

My luck finally took a turn for the better when my mom got a new job and added me to her insurance. I found out Tuesday that I am approved! Surgery date Feb 1st. liquid diet starts Monday.

Wish me luck!