Insurance Appeal

[Sophie74656 1,572]

Hi everyone, I haven't posted in a while

My dad is in the process of getting his sleeve, he's scheduled for July 5. Unfortunately he just found out that his insurance denied him because his BMI was under 40. I know his BMI is over 35 and he has diabetes, so I don't really understand why he was denied. His surgeon is filing an appeal. My question is just to aleviate his anxiety, has anyone been successful with getting an appeal approved? And yes, I know it all depends on your individual insurance. I just want to be able to tell him that people have been successful with an appeal.

He's so frustrated with the whole process, all the tests he's had to go through, he's already had to reschedule once and this may just make him loose hope on having surgery at all.

[kell911 62]

His insurance has criteria that has to be met. BMI with the 1-2 comorbidities, with possible other requirements. Do you know what they are?

[Sophie74656 1,572]

Yes, his insurance says a BMI of 35 with a comorbidity such as diabetes should qualify. He is diabetic and I'm sure he has apnea. So he should have been approved. I'm really hoping someone just overlooked something. My mother is going to call herself tomorrow and talk to the insurance but he is so upset right now.

[dstgirl11 22]

I was denied and successful approved by getting a medical necessity letter from my PCP and calling (2 times) and doing online chats (2) with the insurance company. After my last chat session, I was approved.

[MSinger 348]

I work in insurance and see denial decisions overturned in appeals all the time. Always worth a shot.

[JT2002TJ 170]

You said you are pretty sure he has apnea... Did he get tested (sleep study) as part of this process?

[Sophie74656 1,572]

1 hour ago, JT2002TJ said:

You said you are pretty sure he has apnea... Did he get tested (sleep study) as part of this process?

He didn't get an official test, but my room is right next door and I can hear him through the walls LOL.

[JT2002TJ 170]

Just now, Sophie74656 said:

He didn't get an official test, but my room is right next door and I can hear him through the walls LOL.

Honestly, this should have been part of the application process. Can he get an appointment and do a take home sleep study before the appeal? If he has it, this is probably the biggest thing outside of the BMI.

[Sophie74656 1,572]

1 minute ago, JT2002TJ said:

Honestly, this should have been part of the application process. Can he get an appointment and do a take home sleep study before the appeal? If he has it, this is probably the biggest thing outside of the BMI.

Yeah I'm surprised he didn't have one done, I had to for my pre op requirements. My mother is on the phone with the insurance company at this very moment, if she is unsuccessful then he'll try to get the test done.