Frustrated with BC/BS of New Jersey

[Niecey 0]

I wrote this in another post but wanted to copy it incase anyone has anything they can suggest I do...

I have not posted in a while too because my insurance is dragging their feet. I have BCBS of New Jersey. My whole process started in Sept of 2007. I did my 6 month diet and I'm borderline diabetic. Everything was processed in March then in April they came back and said they needed more info about the 6 month diet. Everytime they ask for something they say it's another 30 business days. So by the end of May they said it was still being reviewed. I asked why it was taking so long and called every other day. They said they would have to send an email and that response would take another 10 business days. I asked for a 48 hour expedided review and still no response. My DH talked to his HR person who sent an email asking what the hold up was and that this was the 2nd time they did this and they needed them to get on it. Dr. Morton's office, Amy, has been wonderful about calling everyday. Amy now has an actual person she can talk to, Jennifer, a part time nurse that works for BC/BS of New Jersey, and this lady has asked for additional info showing I have dieted for years and what diets I have been on. Amy explained that this was not in the original request but the letter from my doctor in Sept of 2007 already stated all the diets I had been on and I have had my PCP for the past 7 years. Jennifer asked that it be resubmitted, which Amy did and that was a week ago. Now BCBS of New Jersey is not returning of her calls. How can insurance companies get away with this? I have not even been denied so I can appeal it. My guess is they have no reason to deny me so all they can do is string me along hoping I go away. Meanwhile I know that I am getting closer to needing to be on insulin. My dad died from diabetes. I don't want to start that process. Isn't it a known fact that the lap band helps get rid of diabetes? Wouldn't someone at BCBS of New Jersey realize that in the long run the lap band will be cheaper on them? Sorry to rant but this seems so wrong that they can get away with this. Thanx for listening.

Denise

[shavone76 0]

Wow that's craze because they approved me in one day. I will be banded tomorrow! It's a shame...

Shavone

[emily111 3]

thats crazy they are treating you like that I did the 6 month diet and one of the notes my dr did not write wat she was supposeed to. But I also had 5 months with the nutritionist. I would suggest you get the name of the person working on your case and send them a letter certified.. then I would also ask your PCP to do a peer to peer. I hope it all works out :biggrin:

[shavone76 0]

It amazing how different doctors have you do all these different things. I basically went to one visit with the Dietician,one suppor mtg, one visit with the Pysch, one for the Barium swallow and my PCP. It was nothing to it. I think 5mths with a dietician and then on top of that some want you to lose weight first... I don't think they know it's a disease and if it were that easy, we wouldn't need to have the band.. Thank god for my Dr. Gorjala at Surgery South in Atlanta. As soon as I was approved they scheduled be 2wks out. I would think that after the approvals, Dr's would want to go ahead and schedule the surgery soon because insurance changes fast.... Just venting....

[Niecey 0]

Well I finally got my answer. I was denied!! "Office notes documenting supervised weight loss were requested but not provided. Criteria for medical necessity has not been met." If you say you didn't get the documents you needed then how can you determine it's not medically necessary??? I have all the paperwork the insurance received 3 times (so they could prolong it 30 days each time) and it's all here. I could just cry. I am so ready to get this surgery. Both of my sister-in-laws got the surgery and they look great. Everyday I'm doing the treadmill, trying to watch what I eat and nothing, no results unless I almost starve myself and then I'm so hungry. So now I am going to appeal it. I did find a 19 page long document on the Blue Cross/Blue Shield website on appealing, greivances, etc. It actually goes up to Level 5 and after that you go to Federal Court. Wow, do I have a long road ahead of me? I am not going to give up. Insurance companies should not be deciding the fate of our life. If my doctor says it's medical neccesary and would provent my start of diabetes then I should be able to get this procedure. They did not deny me from having a tubal ligation and that had nothing to do with helping my health in the long run. I know I could just get it and pay out of pocket but we also need a new car. I don't want to put my family in $30K+ debt. Wish me luck!!

Neicey

[Niecey 0]

I have been approved YEAHHH!!!

Niecey

[BABY-LYN 9]

what did you do to finally get approved? i was denied because i have a bmi of 38.5 and no uncontrolled comorbilities. i don't know what i should do for the nest step.

[MiniBand 0]

Man I am tired of BCBS of NJ. All they do is tell me they have expedited my file but I know they haven't. Because when I call and get one guy he says, they shouldn't have told you that, but today I will expedite your file. They have had it over 30 days now and with the long weekend it will be like another whole week or so.

My BMI is 37 and I have GERD, tt2 diabetes, metabolic syndrome, fatty liver, pre-hypertension, IBS and if I probably went to take a sleep study I think I have mild sleep apnea... My diabetes is not well controlled but I am trying to do a better job for myself. I don't know what it takes. I can lose like 5 or so pounds and then my metabolism stalls and I get frustrated and I gain it back. Plus I am about hit that big change in my life and I know it is going to be much much harder to get it off. It already is!!!!

COME ON NJ BCBS, please approve me, and all us other people that need to have this technology!!!!!

Let me know what you do, and I let you know what happens with me ok Baby-Lyn!

Edited to add... Baby-Lyn where I work we have several choices of health insurance, one girl wasn't big enough and she gained enough weight to get the surgery, you might consider that since you are almost there. She had United though.

Edited August 29, 2008 by MiniBand
add a note

[BABY-LYN 9]

i'm really thinking about trying to gain the little amount of weight needed. i have an appt on wed. of next week with the pulimanogist(forgive the spelling)? hopefully they will weight me then. i'll be sure to eat and drink alot over the holiday. i may even wear my heaviest clothes. maybe that will work.

i'll keep you all posted. i just really wanted to get started towards my healther life.

[di1138 8]

I have horizon bc/bs (and I mean BS) of NJ too. After 6 weeks they came back to me and said I needed the 6 month diet too. Like you I was not officially denied. Even though the doctor had submitted all my info regarding co-morbs, I wrote an appeal letter. Thank goodness I am a pack rat. I sent them records of my years on and off with Jenny Craig plus my PC doctor gave me copies of my records for the last three years showing how my weight yo-yo and my health declined. I faxed volumes of paper to them and 3 days later I was approved. Good luck and keep fighting!

[di1138 8]

oops for got to tell you my bmi was 39.2 and they want 40. Stupid huh?