Denial advice

[izzy13 117]

I'm somewhat new here but have been reading about everyone's experiences for the last month and it seems like a great place to ask advice. So

I thought I met the requirements of my insurance, bmi is 35.2 and I have had high blood pressure my whole life. I do take a bp med that seems to keep it under control. My insurance requires a bmi btwn 35-40 with one co-morbidity. They list medically refractory hypertension as one.

I unfortunately got my first denial today saying my hypertension is controlled by one med and although I have sleep apnea it's only mild (they require severe). Has anyone been in a similar situation and gotten approved??

Of course I'm going to call my surgeons office Monday and they seem the type that will fight for me but I'm just worried that I'm going to get denied all together just because I finally found a high blood pressure med that kinda works and only has a few side effects. It really also sucks getting a denial letter on Friday...I guess I'm a little anxious lol!

Thanks!!!

[ironpoorer 88]

There are always alternatives, self pay- either in the US or in Mexico, there is often financing if you qualify. Many doctors do the sleeve in conjunction with a hiatal hernia repair and the VSG is at a much reduced cost (my Dr in Dallas charged $3500 for this option, following his diagnosis that I indeed had a HH via EGD/scope). Don't give up hope!

[Sophie74656 1,572]

My bariatric center had a form for me to sign that they would handle any appeals. Ask your surgeon if they will contact the insurance company for you

[Kooky1 96]

There are always alternatives, self pay- either in the US or in Mexico, there is often financing if you qualify. Many doctors do the sleeve in conjunction with a hiatal hernia repair and the VSG is at a much reduced cost (my Dr in Dallas charged $3500 for this option, following his diagnosis that I indeed had a HH via EGD/scope). Don't give up hope!

I may be misreading, but your doctor in the US did the VSG for $3500 or he did the hiatal repair for $3500?

[FreeTheSkinny66 9]

@@izzy13 Just curious - who is your insurance through? I'm in a similar situation - < 40 BMI, and my sleep apnea is only mild (severe is required) and I do not have high blood pressure or diabetes....and I am very worried about getting approved (not there yet).

I'll be watching the responses you get. And will keep my fingers crossed for you. I've read sometimes an appeal goes to a "peer to peer" review with your doctor and one from the ins co. That personal "touch" might make a difference.... |??

Edited March 26, 2016 by FreeTheSkinny66

[izzy13 117]

I am from upstate ny and have CDPHP apparently they are easier then most m, they don't require any supervised diet so if you meet the criteria boom you're in. I thought I had it In the bag with my high blood pressure. My sister had surgery last year but her bmi was 40 (same ins) with no issues she seems to think on appeal from the doctor they will approve me she thinks it's just a formality that the denied me. I will def keep this updated!!! And if anyone has any similar situation if love to hear any advice. I don't know if I could afford self pay, NY is crazy expensive for everything!!!

[FreeTheSkinny66 9]

I have Anthem BCBS (in CT) , and it is a CDHP. It requires 1 co-morbidity if BMI is under 40 and 6 months continuous active participation in a weight loss plan with serial documentation within the last 2 yrs. I actually did Ideal Protein through a doctor's office Jan 2014 through Aug 2014 (lost 45 lbs and gained all back in 1.5 yrs - ugh). I would say that is within the last 2 years - I was still on the program 2 years ago! But my surgeon's office has me on a 6 month thing with them as they said it was too long ago - I think they are wrong.

This insurance stuff is making me nuts!

[lolarose13 147]

Hi Izzy! Crossing the fingers for you!

If you don't mind, what insurance do you have? In going for a revision consultation next week and I'm barely 35 BMI with PCOS, insulin resistance and high cholesterol. I know appeals are frustrating but I'm sure you can win this one!

Sent from my iPhone using the BariatricPal App

[izzy13 117]

So no luck yet, I called the office and the manager that deals with insurance is out today and I'm sooo tempted to call the insurance company myself but I don't want to sabotage anything and I'm sure the doctors office has experience with this stuff.

@@lolarose13 I have CDPHP which is a local insurance to upstate NY it's actually a really good plan but apparently my high blood pressure is not medically refractory hypertension bc I only take one medication. Pcos isn't a qualifying co morbidity for my plan which is unfortunate bc I blame that and my endometriosis on having a metabolic disease which I think contributes to my weight and my inability to lose and keep it off (well that and all the Desserts I eat, I'm definitely not one to blame all my weight issues on other things, my poor eating habits contribute I'm sure!! Lol)! Sounds like you have a fighting chance though depending on your insurance requirements, I wish you luck!!

[izzy13 117]

So I spoke to the doctors office today, the insurance changed their criteria and the office wasn't aware. A bmi less then 40 requires my blood pressure to be so uncontrolled I'd have to take at least 3 medications. I've have hbp my entire life and have never heard of anyone being on that many meds at once. I think it's a way they can exclude the lower bmi's from surgery.

I have to initiate an appeal, I'm having my primary dr write a letter, hopefully they will see that even the dr treating my bp thinks surgery is in my best interest. But the surgeons office told me to put on my big girl pants as this appeal process is going to take a long time and won't be easy so fingers crossed but I'm not going to get my hopes up - disappointment hurts too much!!