Anthem BCBS Appeal

[middlebeaver 10]

Hi guys!!

So I received the dreaded denial. My doctor and I sent in an appeal so now I wait, again. I know the time frame is 30 days, but what is your experience with appeal time frame before you are notified?

Also, I would like to how many were approved or denied after an appeal. I look forward to hearing from each of you.

[thatmeanone 240]

Any idea why you were denied?

I have the same insurance but for NYC employees and my surgeon gave me a date of August 22, pending approval after my 6th weigh in on August 5.

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[bornthisway622 51]

i have the same insurance im also in nyc something in your paper work might have messed that up my wls is july 20 and it took 3 days to get approved. i hope something goes good for you wish you luck

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[middlebeaver 10]

I was denied as "not medically necessary". Basically, in a nut shell, they believe my last procedure failed because I didn't follow the program, which is not true.

[Tommy s socorro nm 12]

Hi guys!!

So I received the dreaded denial. My doctor and I sent in an appeal so now I wait, again. I know the time frame is 30 days, but what is your experience with appeal time frame before you are notified?

Also, I would like to how many were approved or denied after an appeal. I look forward to hearing from each of you.

I was denied. Then I did a sleep study for sleep apnea and insurance approved it..

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[thatmeanone 240]

I was denied as "not medically necessary". Basically, in a nut shell, they believe my last procedure failed because I didn't follow the program, which is not true.

I would ask your surgeon to request a peer to peer review. They seem to have good results from what I have heard.

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[SweetPeas 117]

While I was in the process of doing the 12 week supervised bariatric weight loss group program my insurance (BCBS) notified me that this program wouldn't "count" and I would end up being denied. They required me to do three additional visits with a NUT instead of the more stringent 12 week program (and the doctor's program has one NUT visit at the beginning and another right before surgery, and then several post op). It was irritating, especially because the hospital still required the 12 week program.

Thankfully the doctor's office had the insurance folks do a preliminary review to check before sending in for the final approval. Oh- one more irritation was that a lady in my group program had the exact same insurance and they did not require her to do the 3 NUT visits. I considered arguing it with BCBS but figured it would only delay my ultimate goal so I just did the additional NUT visits. During all of this there was a sleep study which diagnosed me with severe sleep apnea, so that also made my case stronger for approval.

[SuzieQ56 4]

Issue isn't the insurance carrier it's what is in the specific contract. I have BcBS of KS I'm a state employee office said not have issues with BcBS plans told the they would mine as our group doesn't like to approve anything. It took them 3 tries over a 9 month period before I was approved even with a BMI over 50. Thank god I work in medical industry so I knew what to expect and how to head them off. Some insurance companies will try to get out of paying for anything but they sure want your premium. I had sleeve June 2015 have lost 180 lbs as of beginning of this month but need revision to bypass as stomach has pulled up into esophagus causing pain and nausea even when drinking plain Water. We have started the fight with BcBS as they are saying not medically necessary since I have lost over 50% of needed weight loss within 2 year period per contract. Need surgery to fix medical issue not for weight loss. Daaaa. Fight is on

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[SusieT 43]

I have BCBS of MN. I was required to do 6 months of medically- supervised weight loss attempt, as well as have a psych evaluation. Was certified last Feb and told it was good for one year. . Got on surgery schedule after I thought, prayed, and researched more. Had RnY on June 20th.

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[middlebeaver 10]

Susie Q, i had the sleeve in 2013, and lost close to 70lbs. My doctor at the time sorta went MIA. Once I had the sleeve he was done. I paid for the sleeve with the hernia program. Not once did I talk to a dietitian, no pre opt what so ever. I sent my appeal in last week, now I'm just waiting for their decision. I was originally scheduled for surgery July 25th, I don't see that happening at this point.

[mskittykat03 113]

Hi guys!!

So I received the dreaded denial. My doctor and I sent in an appeal so now I wait, again. I know the time frame is 30 days, but what is your experience with appeal time frame before you are notified?

Also, I would like to how many were approved or denied after an appeal. I look forward to hearing from each of you.

I also have anthem and was originally denied. They said I didn't qualify (I certainly do). Anyhow, the woman who processes the insurance paperwork at the surgeons office called them and discussed. Turns out, that Anthem is very picky. They want the paperwork done in an exact manner. My denial was turned into an approval in 2 days (over the weekend btw).

Surgery completed on time in April 2016.

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[middlebeaver 10]

Ins Finally approved!! Tuesday I called and I was told the appeal was denied, for the same exact reason the pre cert was denied in the first place. Apparently, who ever handles the appeal did not even take the time to read the appeal letter and documents. I called the appeals department and asked the names of the individuals involved in the denial and their credentials? She claimed the file was still "open" and they had one more day to make a decision, which was completely different than what my nurse said and a rep. After praying my little heart out; I received the call I was approved!!! What a journey! Fight, fight, fight!

[bia1nca1 38]

I have BCBS of MN. I was required to do 6 months of medically- supervised weight loss attempt, as well as have a psych evaluation. Was certified last Feb and told it was good for one year. . Got on surgery schedule after I thought, prayed, and researched more. Had RnY on June 20th.

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I have the same insurance, I just finished my last nutrition appt and paperwork will be submitted 8/15/16. Did you do a sleep study? I hope there aren't any issues. How long did it take them to approve you?

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[middlebeaver 10]

Well my surgery was revision, is yours? I had the sleeve in 2013. I have sleep apnea so I didn't have another sleep study. If this is your first wls I don't think you will have any problems at all! I received the denial 2 weeks after submitted. It's nearly been two months. I started this in January. I know you must be excited!!

[northcountyr1 199]

My insurance would not pay a dime, so we decided to pay "out of pocket" for by sleeve. .got it on sale. . $11,111.

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