Insurance denied me [emoji22]

[JennAsVSG 1]

Hi - I'm new to this WLS community and I could really use some encouragement right now

I just spoke with my surgery center to make sure they had all my paperwork and to see if they had submitted my information to my insurance company - and they did - and today my insurance company called them and said my surgery was DENIED because they didn't think my co-morbidities and BMI qualified me for the surgery to say I am disappointed is an understatement! My insurance coordinator at my surgery center did say she has already sent a message to my surgeon (he's on vacation this week and will not be back until Monday) and that he will more than likely call my insurance company for a peer-to-peer review - she said she would call me next week with an update

A little info about me: I started considering this surgery last year and began actively pursuing it in January - going to an info seminar, choosing a surgeon, starting my NUT appointments (insurance required 3 - I'm on my 4th), did my psyche eval, my endoscopy, and had my medical clearance - I even have a 'tentative' surgery date of 09-08-16. My BMI is 36.3 and I have hyperlipidemia and GERD as my co-morbidities - I really did NOT think I would be denied - my surgeon said I was the 'ideal' candidate because I didn't have an over abundant amount of weight to loose and I wasn't 'sick' with diabetes, hypertension, or anything like that yet - I'm just super bummed

Has anyone had their insurance company deny them only to approve them after speaking with their surgeon?

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[KristenLe 5,979]

I hope they approve after the peer to peer! Stay strong!

[GeekyChicLa 15]

Wow. That really sucks. I'm worried that they may deny me, too. I go for my last weigh in July 1st. My MD keeps asking me if I'm sure my BMI is high enough to need surgery. (I think I'm around 37)

My insurance requires a 6 month medically supervised weight loss effort and 2 co-morbidities. I'm like you and on my last stages. Had to pay out of pocket for psych evaluation as well as other things that my insurance would not cover.

I've read on here where some have submitted an appeal...have you thought of doing that?

[BarefootDrummer 108]

From what I've read, I think the docs are pretty good at pushing the insurance companies a bit to get them to approve. I've heard the patient can call them and push too.

I know the process is hard enough, you don't need the insurance company getting in the way. Good luck!!!

[JennAsVSG 1]

Wow. That really sucks. I'm worried that they may deny me, too. I go for my last weigh in July 1st. My MD keeps asking me if I'm sure my BMI is high enough to need surgery. (I think I'm around 37)

My insurance requires a 6 month medically supervised weight loss effort and 2 co-morbidities. I'm like you and on my last stages. Had to pay out of pocket for psych evaluation as well as other things that my insurance would not cover.

I've read on here where some have submitted an appeal...have you thought of doing that?

My insurance required the psyche eval, 3 months of nutritional appointments, weight loss/diet history - I paid out of pocket for my ALL of it so far - if they do not approve it after the peer to peer with my surgeon I will look into filing my own appeal

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[anniebanana 167]

You can appeal their decision. My first attempt at WLS was in 2011. My insurance denied me, but I wrote a letter and they approved it. Then I changed my mind about the surgery at that time I think things have changed and they are really much more strict, but it's always possible. It would be completely ridiculous if you had to gain weight to be approved. My current insurance company denied me when I tried to bypass the full 6 month workup based on my history, but as soon as I met their required 6 months waiting period, they approved me within 24 hours. Good luck, I'm sure you must be so frustrated!

[ChrisInc2 56]

So sorry to hear that you got denied but like the last post said she wrote a letter that'll be a good thing to do try to get your mom or significant other to write one for you and just tell them how depressed you are living like this and list some things that'll make your life better if you we're to have this surgery. The Dr office can submit it for you they do listen and usually approves. Hope this helps, wishing you the best.

[OutsideMatchInside 10,166]

@@JennAsVSG

If you already have GERD why are you getting the sleeve? Is your GERD hiatal hernia related?

[kmorri 1,689]

@@JennAsVSG Have faith! I've heard several folks have really good results when the surgeon does a peer to peer review.....that's when your surgeon actually talks with a doctor who works for the insurance company......Most any time I've heard folks on here that had the peer to peer they were approved.

I suggest waiting for your surgeon to get back from vacation and let him do the peer to peer first.....then if it's denied file an appeal.

I'll keep my fingers crossed for you!!

[JennAsVSG 1]

@@JennAsVSG

If you already have GERD why are you getting the sleeve? Is your GERD hiatal hernia related?

@@OutsideMatchInside - no not related to hiatal hernia or anything structural like Barrett's Esophagus, more than likely weight related - that's why my surgeon likes to do an endoscopy on every WLS patient to see if there is anything that needs corrected (hiatal hernia) or would cause a WLS procedure (VSG) to be contraindicated (Barrett's Esophagus)

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