Denied by insurance

[KingKev_VSG 4]

Hi all! Soooo I’ve been browsing the forum and saw quit a few people getting denied for surgery, by their insurance. I’ve done all my clearances and even have my surgery date (Sept 8!), but i’m just waiting on the approval by insurance. My question is for the people that have been denied. Why were you denied by your insurance and did you submit an appeal? I’m 80% sure i’ll be fine …I just have the pre surgery jitters i guess 😬

[BigSue 1,414]

There are lots of reasons an insurance company can deny surgery, and some are easier to resolve than others. My first request was denied because my insurance company added a requirement (after I had already started the process) for a letter from my PCP with some specific wording about being "medically cleared for surgery." My surgeon's office sent an example letter to my PCP with the required wording, and once my PCP submitted the letter, my appeal was approved.

Most clinics check the insurance requirements at the beginning of the process because they don't want to waste their time or yours if you're not going to qualify.

[KingKev_VSG 4]

1 hour ago, BigSue said:

There are lots of reasons an insurance company can deny surgery, and some are easier to resolve than others. My first request was denied because my insurance company added a requirement (after I had already started the process) for a letter from my PCP with some specific wording about being "medically cleared for surgery." My surgeon's office sent an example letter to my PCP with the required wording, and once my PCP submitted the letter, my appeal was approved.

Most clinics check the insurance requirements at the beginning of the process because they don't want to waste their time or yours if you're not going to qualify.

1 hour ago, BigSue said:

There are lots of reasons an insurance company can deny surgery, and some are easier to resolve than others. My first request was denied because my insurance company added a requirement (after I had already started the process) for a letter from my PCP with some specific wording about being "medically cleared for surgery." My surgeon's office sent an example letter to my PCP with the required wording, and once my PCP submitted the letter, my appeal was approved.

Most clinics check the insurance requirements at the beginning of the process because they don't want to waste their time or yours if you're not going to qualify.

Thank You for responding! I’m glad you were approved after your appeal. I feel better knowing there’re options.

[vikingbeast 987]

Also, just from (very) recent experience, make sure your bariatric clinic's insurance coordinator knows their stuff. I got a letter from my insurance after they submitted saying "hey, we need X, Y, and Z before we can determine," except I know for a fact X, Y, and Z were submitted.

So when I called the insurance coordinator, she said this is normal, what happens is they open a request online which generates an automatic letter to be sent with what's needed, but it happens before the process allows them to upload the clearances, so it appears "missing".

I had my answer back in 3 business days.

[KingKev_VSG 4]

9 minutes ago, vikingbeast said:

Also, just from (very) recent experience, make sure your bariatric clinic's insurance coordinator knows their stuff. I got a letter from my insurance after they submitted saying "hey, we need X, Y, and Z before we can determine," except I know for a fact X, Y, and Z were submitted.

So when I called the insurance coordinator, she said this is normal, what happens is they open a request online which generates an automatic letter to be sent with what's needed, but it happens before the process allows them to upload the clearances, so it appears "missing".

I had my answer back in 3 business days.

Ahh good to know… I’ll make a call to my surgeons office tomorrow to see the status of the approval. Thanks for responding!

[vikingbeast 987]

1 minute ago, KingKev_VSG said:

Ahh good to know… I’ll make a call to my surgeons office tomorrow to see the status of the approval. Thanks for responding!

I'm such a control freak (I'm a project manager!)... I actually discovered the hidden place on my insurer's website where I could track it. I actually knew about the approval before my clinic did 🤣

[KingKev_VSG 4]

I’m the SAME WAY! That’s why i’m stressing because I’m not in control of the outcome. I’ve been looking at my insurance website for days…just to see if any new claims popped up😩

[vikingbeast 987]

On my insurance (CIGNA) it was under coverage and then precertifications.

[FutureSkyDiver 76]

I say it all the time here, but in case you haven't seen it yet.

Appeal, appeal, appeal. Insurance companies are very vested in denying coverage for whatever minuscule reason they can. It saves them tons of money. Heck, it is easier with less paperwork to deny a claim and hope the insured doesn't appeal than it is to approve a claim, even when there is coverage. Never accept the first denial from an insurance company...or the second or third if you are sure you should be covered under your plan. They make more money when you keep quiet.

[vikingbeast 987]

Also, if you are denied, talk to the benefits coordinator at your work, because in many cases they can overrule denials, especially for larger companies that are self-pay.