Denied in Maryland/BCBS/depressed/what nxt?

[yiya 0]

I've been working on this since February, have had every test known to man (it feels like, anyway). I have a "low" bmi of 35, have sleep apnea, arthritis, gerd, insulin resistance, etc, but was denied because I'm not 100lbs overweight, even though my insurance reads that your bmi can be as low as 35 w/ co-morbities. Even my denial letter admits I meet the bmi w/ co-morbidities requirement. The insurance uses double-talk so they have a way out of paying. My Dr (Dr Moenolmolki) said, in so many words, don't bother to send an empathetic appeal letter to insurance---they could care less. He suggested hiring a lawyer to write a letter. I don't know if it's worth spending the $450. to do that. Anyone here know of anyone who's been approved on denial with a similar situation? Or should I look into Mexico self-pay? My only concern w/ that is, if I have complications down the road, will insurance cover it? I don't want to rack up $1,000s in medical bills after surgery. Help! :frown:Thanks for any encouragement/advise you can give.

[luvmy2dogs 2]

Don't give up. Be persistent. Keep nagging them, and they will come around. I went through the same thing. Been trying since Feb. I have BCBS of Georgia. I just got my approval last week. They deny hoping you'll just give up. Do you have clinical info proving your sleep apnea, etc...

[tonyavessels 0]

I've been working on this since February, have had every test known to man (it feels like, anyway). I have a "low" bmi of 35, have sleep apnea, arthritis, gerd, insulin resistance, etc, but was denied because I'm not 100lbs overweight, even though my insurance reads that your bmi can be as low as 35 w/ co-morbities. Even my denial letter admits I meet the bmi w/ co-morbidities requirement. The insurance uses double-talk so they have a way out of paying. My Dr (Dr Moenolmolki) said, in so many words, don't bother to send an empathetic appeal letter to insurance---they could care less. He suggested hiring a lawyer to write a letter. I don't know if it's worth spending the $450. to do that. Anyone here know of anyone who's been approved on denial with a similar situation? Or should I look into Mexico self-pay? My only concern w/ that is, if I have complications down the road, will insurance cover it? I don't want to rack up $1,000s in medical bills after surgery. Help! :frown:Thanks for any encouragement/advise you can give.

Insurance companies can be a pain in the butt sometimes. I wouldn't give up! I would be calling them once a day! But hiring an attorney may work but what is the $450? I mean really! compared to weight loss and happiness. I would definetly have the doc sign the document also before you send it to them. Self pay can get real expensive and you dont want to rack up bills and ruin your credit! Some hospitals have a huge discount program to help with self pay, or if you can't get any help from your insurance co I would also recommend getting help from the state. They should have some type of medical plan throught your dept of human services, I would sign up for that! Normally the state will pay for it as long as it is medically necessary all you need is documentation from your doc. :wink2: keep your head up! don't give up!

[lafrogura 0]

Don't listen to your doctor! Write a lengthy appeal letter yourself and send it in! there have been many people do that and then get approved. Don't even tell your doctor's office you're doing it.. DO NOT GIVE UP!! I have BCBS also.. it just takes a little nagging by the patient. Use your right to appeal. Then if they deny again, then hire a lawyer. You are allowed more than one appeal. usually you can appeal up to a 3rd level. APPEAL, APPEAL, APPEAL ...

[nazzy 1]

i have bsbs michigan general motors im on wait im sure hoping they aprove me mine is 50 bmi plus i had double knee replacements last yr so im hoping they do me,gl

[LISAMARIE1158 0]

did they say why he denied you? l was also denied by B/C...but l called them daily for probably two weeks. l got to know them also personally...in y book it said l didn't even need approval, yet l did. whe l got denied l was hurt, angry and very pissed off...finally l found out that l was denied bec l was missing a paper in my file...given the paper and l was approved...CALL them....be a pain in their neck...call them again and again...eventually you will find someone who cares...l was lcky to find someone who has the surgery a few years ago....lol....be strong..lf all else fails l would spend them money on an attorney...l contacted obesity law .com...they accepted my case, bec l really had a case....BUT l got my approval the same day Obesity law took the case and l never needed them...Good luck..Be a cheerleader for yourself....

[yiya 0]

Thank-you all for your suggestions and encouragement, which are greatly appreciated!!!! I will follow up and keep trying....thanks again!:biggrin:

[neverB4 2]

Working for BCBS myself, you have appeal rights. Follow thru with them first. Then check into your local Dept of Insurance if needed. They usually pay closer attention when they become invloved. Also, you have the right to ask for an external review outside of the BCBS dept. BCBS woon't give if it's an exclusion in your policy, but since you meet the 35 BMI with co-morbidities, they can't keep denying by law. Again, your state's dept of insurance maybe can help before you get a lawyer.

[yiya 0]

Thanks, I appreciate your encouragement and will keep trying!!! :-)

[yiya 0]

Working for BCBS myself, you have appeal rights. Follow thru with them first. Then check into your local Dept of Insurance if needed. They usually pay closer attention when they become invloved. Also, you have the right to ask for an external review outside of the BCBS dept. BCBS woon't give if it's an exclusion in your policy, but since you meet the 35 BMI with co-morbidities, they can't keep denying by law. Again, your state's dept of insurance maybe can help before you get a lawyer.

Thank-you for the info! Do you know anything about 3rd party administrators? My policy has NCAS as the 3rd party administrator. My understanding is that they interpret and administer my employer's policy, they don't write it. Do you think that will make a difference one way or another? Should I speak to someone in my HR/benefit department? (although it's the most disorganized HR dept I've ever seen--you can never get a person when you call, and rarely get a call-back...but that's another story!) I am an RN with a large healthcare organization/hospital. Thanks again!!

[yiya 0]

Great news today!!! I sent out an appeal letter today (which a LBT member graciously helped me compose), but then received a call from my doctor's office that I was just approved! I think it's because I called the ins company a couple of days ago and challenged them regarding the wording in my denial letter which contradicted itself. I insisted that they send me a copy of the policy, which before they have always refused to do. The lady I spoke with consulted with her supervisor and when she came back to the phone, she said they would mail it to me. Instead, I think they realized the contradiction, and approved me!! YAY!!! Thank-you all for your encouragement and support!!