Appeal assistance

[pb88 1]

I already had my sleeve surgery. I got a "preauthorization" from my insurance (Blue cross/blue shield of TX) for medical necessity (over BMI 40). I just got all the EOBs and every single one of them was denied. When I called the insurance they said that the "insurance" may have approved it, the "plan" didn't as they don't cover Bariatric surgery. He said I should appeal but because employer has that clause it's going to be a tough fight.

Any information you can provide on what to include (or exclude) in the appeal would be great.

I've not gotten a response from the doctors office (except surprise), so I think a peer to peer review is out.

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[cbonet 336]

I appealed with statements from my other doctors making it a medical necessity. If you have other conditions get a letter of medical necessity from each one, cardiologist, General dr, endocrinologist, orthopedic..... My appeal was won fairly quickly.

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[JAM72 16]

@@pb88 - Have you had any luck sorting out your insurance issue? I also have BCBS TX and your post makes me nervous!

[pb88 1]

It has been resubmitted by the doctors office and I should know next week if it gets approved or if I have to appeal. Doctor's office said they have never had this situation before.

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[JAM72 16]

@@pb88 - Sending good thoughts and prayers your way. Can I ask - which doctor did you use?

Edited September 21, 2016 by JMill 72

[bellabell1 3]

I had BCBS & I went through the same thing & I learned that it also has something to do with company you work for if its insurance through your job ... & I worked for a non/ profit organization ,Sometime that employer will have that claus in there where none of the plans will cover Bariatric surgery no matter which one u choose PPO,HMO it dnt matter & that's when i dropped ????mines ...

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[cindym44 75]

It's not the insurance company, it's whether the company you work for opts to include bariatric surgery in it;s group policy. If your company does not, I don't know how your surgery would be covered, especially now. I certainly would turn this over to the surgeon's administrative staff though...they should have known this before they operated on you.

[KristenLe 5,979]

What was the purpose of the prior with then? That's to authorize the surgery based on your benefits! That's ridiculous!

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[JAM72 16]

@@pb88 - I've been thinking of you and wondering if you had any luck with your insurance company. Did they end up paying your surgery bills?

[Fignewton 4]

See if you can get a case mgr at the insurance company to help fight for you.

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